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The role of the medical health officer in British Columbia Loewen, Dale Raymond 1979

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THE ROLE OF THE MEDICAL HEALTH OFFICER IN BRITISH COLUMBIA by DALE RAYMOND LOEWEN, M.D. Queen's University, 1966 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE i n THE FACULTY OF GRADUATE STUDIES Department of Health Care and Epidemiology We accept t h i s thesis as conforming to required standard THE UNIVERSITY OF BRITISH COLUMBIA January, 1979 (£) Dale Raymond Loewen, 1979 In presenting th i s thes is in pa r t i a l fu l f i lment of the requirements for an advanced degree at the Univers i ty of B r i t i s h Columbia, I agree that the L ibrary sha l l make it f ree ly ava i l ab le for reference and study. I further agree that permission for extensive copying of th is thesis for scho lar ly purposes may be granted by the Head of my Department or by his representat ives. It is understood that copying or pub l i ca t ion of th is thes i s for f inanc ia l gain sha l l not be allowed without my writ ten permission. Department of The Univers i ty of B r i t i s h Columbia 2075 Wesbrook Place Vancouver, Canada V6T 1W5 Date i i ABSTRACT The r o l e of the Medical Health O f f i c e r (M.H.O.) i n B r i t i s h Columbia i s ex-plored i n th i s t h e s i s , looking for consensus on the "job d e s c r i p t i o n . " The evaluation of t h i s brand of community physician i s examined i n a l i t -erature review which considers h i s function i n the three countries of B r i t a i n , the United States and Canada. Some associated discussions of community health services i n these countries i s evident. Education of the Medical Health O f f i c e r i s also explored as a necessary component i n assuming t h i s r o l e d e s c r i p t i o n . The d i v e r s i t y of roles as engendered i n the Canadian provinces i s r e l a t e d to the l e g a l and administrative p o s i t i o n of the B r i t i s h Columbia Medical Health O f f i c e r . The study generally examines the l e v e l of consensus that has existed i n t e r n a t i o n a l l y and n a t i o n a l l y on the r o l e of the Medical Health O f f i c e r and s p e c i f i c a l l y the l e v e l of consensus amongst B r i t i s h Columbia Medical Health O f f i c e r s . A survey questionnaire was mailed to a l l p r o v i n c i a l , regional and c i t y Medical Health O f f i c e r s i n B r i t i s h Columbia to elucidate t h e i r opinions and ideas on what the job d e s c r i p t i o n e n t a i l s and what they f e e l i t should be. The response rate o v e r a l l was seventeen out of twenty or e i g h t y - f i v e percent. Selection, education and experience of Medical Health O f f i c e r s i n B r i t i s h Columbia i s examined i n d e t a i l . Attitudes about the p o s i t i o n and how i t r e -lates to the re s t of the medical community are f e l t to be important aspects to inte g r a t i o n of community medicine with the rest of medicine i n general. The ro l e d e s c r i p t i o n i s divided mainly into Administration (Health Unit Director role) and Direct Services (Community Physician) r o l e . The Health O f f i c e r i i i ( l e g i s l a t e d o f f i c e r role) i s outlined as i t occurs i n B r i t i s h Columbia but t h i s area i s not pursued i n d e t a i l because i t could form the substance of a complete study i n i t s e l f . The r e s u l t s indicated a lack of consensus on the r o l e of the Medical Health O f f i c e r . In B r i t i s h Columbia the v a r i a b l e r o l e i s found to be more a function of personal preference and regional needs than a common set of procedures and pr a c t i c e s . History revealed a constant reorganization and re-evaluation of Medical Health O f f i c e r functions accelerated by rapid t e c h n i c a l , p o l i t i c a l and s o c i a l changes. The need f or a cle a r e r r o l e i s questioned. The Medical Health O f f i c e r i s f e l t to be a ge n e r a l i s t , hopefully with the v e r s a t i l i t y to d i r e c t the " c o n f l i c t -ing goals" of health systems into some kind of organizational sense. His broad outlook i s f e l t to be an asset i n t h i s regard. Five main recommendations resulted from the study with respect to the B r i t i s h Columbia Medical Health O f f i c e r . These were: 1. re-evaluation of the educational program, p e r i o d i c a l l y ; 2. elimination of the marginally u s e f u l administrative functions of the Medical Health O f f i c e r by expansion of the O f f i c e Supervisor r o l e ; 3. re-evaluation'of the s e l e c t i o n process f o r B r i t i s h Columbia Medical Health O f f i c e r s ; 4 . establishment of closer formal l i a i s o n with " c l i n i c a l medicine" v i a the BCMA to eliminate t r a d i t i o n a l b a r r i e r s between the two i v groups and to expand the r o l e of community medicine and; 5. requirements that assure new Medical Health O f f i c e r s w i l l obtain the F.R.C.P. q u a l i f i c a t i o n s to maintain equality and c r e d i b i l i t y with the c l i n i c a l physicians. F i n a l l y , i t i s f e l t that there w i l l be ongoing evaluation and assessment of the Medical Health O f f i c e r r o l e without consensus ever being achievable or even desirable. This i s not f e l t to a l t e r h i s contribution to health systems. The question, "What l e v e l of consensus i s there among B r i t i s h Columbia Medical Health O f f i c e r s about t h e i r r o l e ? " has been answered. There i s none. V TABLE OF CONTENTS CHAPTER PAGE I INTRODUCTION 1 II LITERATURE REVIEW . 3 The Forces of Medicine 3 Organization of Public Health 4 The Role of the Medical Health O f f i c e r 11 Education of Medical Health O f f i c e a r i n U.K 15 Education of the Medical Health O f f i c e r i n the United States . 18 Education of Medical Health O f f i c e r s i n Canada 23 P r o v i n c i a l Variations i n Public Health and Medical Health O f f i c e r Roles 24 Legal and Administrative P o s i t i o n of the B.C. Medical Health O f f i c e r i n the P r o v i n c i a l Public Health Service 31 III METHOD 36 IV ANALYSIS OF DATA 38 Description of Population 38 Levels of Consensus 39 a. A l l o c a t i o n of E f f o r t 39 b. Preparation for Medical Health O f f i c e r Role 43 c. Role of the Medical Health O f f i c e r i n Total Medical Community 47 d. Attitudes About Work and Setting 50 e. New Directions i n Service 50 Levels of Consensus Among Sub Groups 52 Selection of Medical Health O f f i c e r s 53 v i TABLE OF CONTENTS CHAPTER PAGE V SUMMARY AND RECOMMENDATIONS 54 BIBLIOGRAPHY 60 APPENDIX 65 Questionnaire 66 Letter to Provinces 81 v i i LIST OF TABLES f TABLE PAGE I Age D i s t r i b u t i o n of B r i t i s h Columbia Medical Health O f f i c e r s ... 38 II Year of Graduation 38 I I I Level of Q u a l i f i c a t i o n 38 IV Medical Health O f f i c e r s D i v i s i o n of Labour With Respect to Percent of Time Al l o c a t e d to Administration 40 V E s s e n t i a l Administrative Functions as L i s t e d by Respondents .... 40 VI E s s e n t i a l Direct Services as L i s t e d by Respondents 41 VII Marginally Useful Administrative Functions - Those Functions Which Medical Health O f f i c e r s Would Prefer to Delegate to Someone Else 41 VIII How Medical Health O f f i c e r s Would Use Extra Time If It Were Available 42 IX Lay Administrative Functions - Those Functions Which Could Be Delegated to a Lay Administrator 42 X Rating of Areas of Training 44 XI Relevancy to Jobs of Areas of Training 45 XII D e f i c i e n t Areas of Training 45 XIII Previous Experience Recommended for Community Medicine With Average Number of Years Recommended 46 XIV Experience i n Other F i e l d s by Current Medical Health O f f i c e r s .. 46 XV Areas of C l i n i c a l P r a c t i c e That Could be Dealt With i n the Health Unit 48 XVI What Medical Health O f f i c e r s Think C l i n i c i a n s Regard as Areas of Interference by the Health Unit 48 v i i i LIST OF TABLES TABLE PAGE XVII How Medical Health O f f i c e r s Think C l i n i c i a n s Could Use the Medical Health O f f i c e r More E f f e c t i v e l y 49 XVIII Health Unit Programs i n Need of C r i t i c a l Review 51 XIX Diseases Meriting More Attention by Medical Health O f f i c e r s and Those With Feasible Programs to Attack Them 51 XX Need f o r F.R.C.P. i n Community Medicine as Dependent on Individual Level Achieved 52 1 CHAPTER I INTRODUCTION There i s a considerable d i f f e r e n c e of opinion about the r o l e of the Medical Health O f f i c e r . D i f f e r e n t points of view have been expressed about what Medical Health O f f i c e r s should be doing and how they should f i t into the o v e r a l l system of health care. Regional needs, culture, personal preferences and a host of "p a r o c h i a l " pressures shape and determine the Medical Health O f f i c e r s ' r o l e and act as forces which oppose the development of a common r o l e . The issue then, i s whether regional demands d i c t a t e the r o l e or whether a common set of procedures and practices transends regional boundaries, and serve as the basic components of a common r o l e . As a f i r s t step i n determining whether functions transcend boundaries or are dictated by them, we must look at what Medical Health O f f i c e r s are doing and how they view t h e i r functions. This w i l l give us some valuable insi g h t s even i f i t doesn't answer the question on whether a common r o l e for Medical Health O f f i c e r s can emerge. Has the ro l e of the Medical Health O f f i c e r ever been defined c l e a r l y ? What l e v e l of consensus i s there among B r i t i s h Columbia Medical Health O f f i c e r s about t h e i r role? This thesis w i l l examine the l e v e l of consensus that has existed i n t e r -n a t i o n a l l y and n a t i o n a l l y . S p e c i f i c a l l y t h i s research w i l l explore the l e v e l of consensus amongst B r i t i s h Columbia Medical Health O f f i c e r s on t h e i r r o l e . The l i t e r a t u r e review looks at Public Health (Community Medicine) and the Medical Health O f f i c e r from t h e i r development i n B r i t a i n , the United States, Canada and B r i t i s h Columbia. Questionnaire data from B r i t i s h Columbia Medical 2 Health O f f i c e r s i s c o l l e c t e d and analysed and f i n a l l y conclusions and recommen-dations are drawn based on the l i t e r a t u r e and on consensus about the r o l e of the Medical Health O f f i c e r i n B r i t i s h Columbia. 3 CHAPTER II t LITERATURE REVIEW In t h i s Chapter we w i l l be examining the beginnings of the Medical Health O f f i c e r as public health evolved from pr i v a t e p r a c t i c e i n B r i t a i n . The spread of public health, now ref e r r e d to as community medicine, from B r i t a i n to the United States and Canada i s explored and compared. The r o l e of the Medical Health O f f i c e r as i t emerges i n these countries i s contrasted looking for s i m i -l a r i t i e s and consensus on the job des c r i p t i o n . The provinces within Canada are compared with the same idea i n mind and f i n a l l y the l e g a l and administrative p o s i t i o n of the B r i t i s h Columbia Medical Health O f f i c e r i s discussed. 1. Medicine and Public Health Public health has existed since the beginning of medicine i n some varying form. The mainstream of medicine involved the h i s t o r i c a l c l i n i c a l physician, whose background stretched to e a r l i e s t of written records. He was i n d i v i d u a l oriented and patient oriented. The Hippocratic Oath i t s e l f , stressed that the physician (an i n d i v i d u a l ) should l i v e i n partnership with the physician (an i n -d i v i d u a l ) who taught him the ar t , and the whole flavour of the oath i s that of a r e l a t i o n s h i p between the i n d i v i d u a l physician and h i s patient. For thousands of years the i n d i v i d u a l has been coming to the i n d i v i d u a l doctor saying: " I t hurts here", and asking to be helped. In much of t h i s t r a d i t i o n a l medicine, the physician didn't see the patient unless he was s i c k . The well man didn't consult a physician, but the family doctor frequently saw family members i n good health, thereby in v o l v i n g himself 4 i n preventive medicine and obtaining i n s i g h t s which would help him when these i n d i v i d u a l s became sick. Public health, or protection from and prevention of disease i n the community required state involvement and eventually separated from private p r a c t i c e or the mainstream. Community Medicine, the a p p l i c a t i o n of s c i e n t i f i c and medical knowledge to the protection and improvement of the health of the group - c a l l s for orga-n i z a t i o n , a conscious e f f o r t by authority. Some form of organization of p u b l i c health has also existed i n most s o c i e t i e s from the e a r l i e s t times, eg. the state doctors of Egypt and Rome, the medieval l e p r o s a r i a , sanitary inspectors of Arabian c i t i e s and r e g u l a t i o n of brothels. This has always, u n t i l recently, been l i m i t e d by the lack of t e c h n i c a l knowledge and hampered by an inadequate appre-c i a t i o n of the value of health and a lack of s o c i a l understanding. C e r t a i n l y , there was an almost complete lack of organization for community health s e r v i c e s . It has always played a secondary r o l e to the mainstream and consensus on t h i s r o l e has been lacking. 2. Organization of Public Health Is there i n t e r n a t i o n a l or n a t i o n a l agreement on the organization of public health? Public health organization has had to await the enlightened s e l f i n -t e r e s t of those who are capable of g e t t i n g things done, so i t has been prac t i c e d when i t seemed to lead not only to "new pastures" but to more pleasant pastures. Thus, the r i c h i n England played a more active part i n sanitary reform, once they were convinced that the diseases of squalor might endanger t h e i r own l i v e s , as well as those of the poor. The beginnings i n Europe were near the end of the eighteenth century, re-f l e c t i n g varying ideologies of the many peoples. Johann Peter Frank (1745-1821) 5 wrote about s o c i a l medicine as a p o l i c e measure - an expression of the auto-cracy he l i v e d under. His ideas on hygiene i n the classroom, and poverty as a cause of i l l n e s s were way ahead of h i s time but did l i t t l e to r e f l e c t pre-sent day concern for ' p a r t i c i p a t i o n by the people, l o c a l government or doing things with people i n tune with t h e i r culture.' In B r i t a i n , Chadwick's (1800-1890) c i r c u l a t i o n of v i t a l f l u i d s , from pure water to p u r i f i e d sewage, protected water courses, pipes, drains and sewers i n -tact and i n v i o l a t e , return a f t e r p u r i f i c a t i o n to the s o i l - has been as momen-tous for man's progress as Harvey's discovery of the c i r c u l a t i o n of the blood. If he were a l i v e now he would s t i l l f i n d nine-tenths of the world s u f f e r i n g the torments of i n t e s t i n a l i n f e s t a t i o n s from which Europe and the New World, i n following h i s teachings, have escaped. Not only h i s s a n i t a t i o n , but the use of l o c a l government i n pu b l i c health administration and the use of the Medical Health O f f i c e r as a s p e c i a l i s t advisor gave r i s e to f a r reaching e f f e c t s . The appointment of the Medical Health O f f i c e r soon became compulsory and t h e i r ten-ure of o f f i c e protected. Throughout Europe, North America and the B r i t i s h Dominions the general plan of organization followed. However, while Europe gathered i t s administra-t i v e forces at the centre and attacked the problem of how to get the s i c k t r e a -ted, England and the New World got down to Chadwick's s a n i t a t i o n with the res-p o n s i b i l i t y f i r m l y placed upon the shoulders of the l o c a l c i t i z e n s . The influence of England on America was s t r i k i n g . The Shattuck report, (1850) might e a s i l y have been written by Chadwick. Shattuck followed the Eng-l i s h report i n most of i t s main recommendations, including that f o r f u l l time Medical Health O f f i c e r s s p e c i a l l y trained and q u a l i f i e d i n public health and 6 independent of private p r a c t i c e . Despite the report, however, the concept of a well-organized health department, supervised by a whole-time Medical Health O f f i c e r , was not widely applied i n the United States u n t i l the 1920's. The Canadian experience has followed a s i m i l a r pattern to the United States, and e a r l i e r B r i t a i n , i n the establishment of health units. In B r i t i s h Columbia, which became a province i n 1871, the f i r s t Medical Health O f f i c e r was appointed i n 1892 because of a smallpox epidemic. The f i r s t health unit began i n Saanich i n 1921. In 1951, G.R.F. E l l i o t speaking on the evolving r o l e , stated that "the health unit must have a broad approach to s o c i a l and economic problems and must learn to understand and attack medical care, poor housing, mental hygiene, accidents and others." The development of l o c a l health units has been, to a l l appearances, quite haphazard everywhere. In England, they began i n 1831 and the country was cov-ered i n 1875. In the United States, the span was from 1793, i n Baltimore, u n t i l the 1920's. Few things, indeed, are so s t r i k i n g as v a r i a t i o n s i n development of public health amongst countries. Denmark began gratuitous treatment of Venereal Disease f o r a l l patients i n 1790 - B r i t a i n didn't u n t i l 1916. B r i t a i n concentrated on s a n i t a t i o n i n 1848 - France hardly appreciated i t u n t i l 1902. Also, the extent of power wielded by the Medical Health O f f i c e r has been s t r i k i n g l y d i f f e r e n t , within d i f f e r e n t countries and often within the same country. (W.H.O. '75). The Health Commissioner i n a United States c i t y gov-erned on the managerial system, making and executing h i s own laws, but generally l i a b l e to removal by p o l i t i c a l whim, w i l l have enjoyed a very d i f f e r e n t d a i l y round of l i f e from that of a nominated o f f i c i a l i n a European country. The 7 B r i t i s h Medical O f f i c e r of Health, whose duty i t was to discover everything i n hi s area p r e j u d i c i a l to the health of the people was v i r t u a l l y independent of control from the centre and yet the servant of a l o c a l l y elected council with i t s own chairman. In Canada there i s a s i m i l a r i t y to B r i t a i n but the Medical Health O f f i c e r i s not t o t a l l y at the mercy of any l o c a l body because of pro-v i n c i a l c o n t r o l . There i s v a r i a t i o n here amongst the provinces and, as we w i l l see, the ro l e s are changing contingent on p r o v i n c i a l governments, not l o c a l sources of power. In machinery and content, public health - the basic i n s t i t u t i o n created and maintained by society to preserve the l i f e and health of the people — i s , i n Europe and North America, a many splendored garment. (W.H.O. '75). Recent developments i n comprehensive medical care have tended to hasten the develop-ment of a common pattern. Most of the countries which began t h e i r public health i n the nineteenth century movement are once again i n the throes of revolutionary thinking towards the newer goal of s o c i a l medicine, which involves public health i n curative medicine and v i c e versa. The concept of good public health now de-mands a f u l l medical service, at home and i n h o s p i t a l , a v a i l a b l e to every c i t i -zen i r r e s p e c t i v e of the a b i l i t y to pay. B r i t a i n , A u s t r a l i a , New Zealand and Canada are engaged more deeply i n operating schemes of medical care, financed by the State or insurance, according to taste. These have resulted i n increas-ing emphasis on the h o s p i t a l , a phenomenon which every country has experienced to some degree. The future i n Europe and North America may we l l become a f i g h t to prevent the h o s p i t a l from taking c o n t r o l . On the crea t i o n of a Public Health or Community Medicine health structure, the World Health Organization (W.H.O. '75) has come out with four concepts 8 concerning the permanent framework. i . U n i f i c a t i o n of preventive and curative medicine, i i . The need for unity or c o n t r o l , where one governing body of the community needing the service co-ordinates a l l measures of prevention, care and r e s t o r a t i o n under one health s e r v i c e , i s stressed. (W.H.O. '52) i i i . There i s a need for l o c a l government with l e g a l backing for autonomy of action. Problems, when t h i s i s n ' t i n e f f e c t have been evident i n underdeveloped countries, i v . F i n a l l y , i t has been stated that "primacy of preventive medicine i s to be maintained by having health minded rather than disease minded people responsible f o r o v e r a l l planning and the d i r e c t i o n and a l l o c a t i o n of community resources." Where the h o s p i t a l has been included i n the administration, t h i s o f f e r s the best opportunity of preventing h o s p i t a l s from becoming autonomous with un-controlled vested i n t e r e s t s i n curative medicine. I t i s the Medical Health O f f i c e r , rather than the H o s p i t a l O f f i c e r , that should plan. "Public health i n Europe and North America i s a many splendoured garment. Power wielded by the Medical Health O f f i c e r between d i f f e r e n t countries and i n the same country has been s t r i k i n g l y d i f f e r e n t . The development of l o c a l Health Units has been quite haphazard everywhere." These statements from the preceding discussion i n d i c a t e lack of agreement on the organization of p u b l i c health and on the power base of the Medical Health O f f i c e r . 9 R e u n i f i c a t i o n of C l i n i c a l Medicine and Public Health To further confuse t h i s lack of agreement, today public health and c l i n i c a l medicine are moving together again. In some parts of the world they have a l -ready joined, i n others they are s t i l l apart. There has been an uneveness of the advance towards the acceptance of medicine as a s o c i a l science, and of medical and h o s p i t a l care as an e s s e n t i a l agent i n public health. While Scan-dinavian doctors have accepted a co-operative r o l e from the nineteenth century onwards, the professions i n England, the United States of America and France have fought rearguard actions to avoid what they consider to be an infringement of t h e i r l i b e r t i e s . In 1920, the Dawson Committee said i n B r i t a i n , commenting on the need to unify preventive and curative medicine: "Preventive and curative medicine can-not be separated on any sound p r i n c i p l e , and i n any scheme, medical services must be brought together i n close co-ordination. They must likewise be brought within the sphere of the general p r a c t i t i o n e r whose a c t i v i t i e s should embrace ® communal as well as i n d i v i d u a l medicine." The most important expression, of t h i s linkage, i s i n r e l a t i o n to the work of the general p r a c t i t i o n e r , where medical care, based on the family u n i t , can go hand i n hand with health promotion, prophylaxis, health education, r e h a b i l i -® t a t i o n and "stimulation of l o c a l i n t e r e s t i n public health." The b a r r i e r s between c l i n i c a l medicine and p u b l i c health, between medical health o f f i c e r s and medical care administrators are crumbling. Teamwork of a l l c l i n i c a l p r a c t i c e and of that with the s o c i a l services i s required. Public health needs c l i n i c a l medicine - c l i n i c a l medicine needs a community. The present structure of health services r e f l e c t s h i s t o r y and p o l i t i c s , s e c t i o n a l 10 pressures, sheer i n e r t i a , and i t has to catch up now with changes i n the pat-terns of disease, service and care. In promoting the public health, the comm-unity physician (medical health o f f i c e r ) must be d i r e c t l y concerned with the mass problems of today and be able to draw from the community's resources to deal with these, not be li m i t e d to the need of services that h i s t o r y happens to have deposited i n h i s o f f i c e . "By f a r the most important trend i n f l u e n c i n g the future r o l e of the l o c a l health department and medical health o f f i c e r i n Canada i s the increasing r e a l i -zation that society w i l l no longer t o l e r a t e the old fashioned d i v i s i o n between prevention ( l o c a l health department) and treatment (hospital and health pro-f e s s i o n a l s ) . This s p l i t i s said to be a waste of time, e f f o r t and money." More recently i n the United States of America i t has been stated that the private sector of medical care has demonstrated serious inadequacies i n coping ® 0 with such d i f f i c u l t i e s as m a l d i s t r i b u t i o n of services, q u a l i t y c o n t r o l and cost d) containments^ A survey of l o c a l health departments and t h e i r d i r e c t o r s i n 1977, estab-l i s h e d that o f f i c i a l public health agencies are fa r too extensive to be consis-t e n t l y overlooked i n the development of the nation's health p o l i c i e s . The United States has i n place an unevenly operative p u b l i c i n f r a s t r u c t u r e of comm-unity and personal health services - understaffed, underfunded and widely i g -nored. The possible benefits that might derive from correcting these neglects needs close attention. Reorganization of the B r i t i s h National Health Service i n A p r i l 1974 brought jo about the creation of community medicine as a service s p e c i a l t y In 1967 S i r George Godber had stated, " I t w i l l be lamentable to the future 11 of s o c i a l medicine and gravely l i m i t i n g to the development of our services i f the present generation of administrative doctors does not seize the opportunity now opening before i t , of providing i n every d i s t r i c t the "community physician" who w i l l promote the organization of medical care i n a l l i t s curative and pre-ventive aspects and i n large areas the e s s e n t i a l l y medical part of better ad-m i n i s t r a t i o n . " A Working Party on Medical Administrators i n March 1970 resulted i n the emergence of "Community Medicine" from a union of the Report on Medical Education (Todd Report) 5 the Report of a Working Party on Medical Administrators (Hunter Report; and the reorganized National Health Service. (N.H.S.) Public health has attracted new i n t e r e s t and i s moving closer to the main-stream of medicine again but i t seems t h i s has not yet resulted i n a c l e a r e r r o l e . 3. The Role of the Medical Health O f f i c e r We w i l l now examine more s p e c i f i c a l l y the Medical Health O f f i c e r attempting to f i n d consensus on h i s functions, a. B r i t a i n The evolving r o l e of the Medical Health O f f i c e r can best be seen by looking, i n i t i a l l y , at the B r i t i s h Experience. The Medical Health O f f i c e r owes h i s con-ception to the formidable genius ChadwickT The reason, or p r i n c i p a l reason, i n his mind, f o r the b i r t h of the Medical Health O f f i c e r was not humanitarian but economic, because i t would make sense i n the e f f e c t i v e ordering of the public health system. He f e l t disease was a waste of human resources. W.H. Duncan was the f i r s t Medical Health O f f i c e r appointed, i n January 1847 but i t was the appointment of Simon i n London the following year which gave the o f f i c e the stamp of authority. He set a standard of responsible and imp a r t i a l comment, on matters of public health, which won him much respect. He recognized 12 the value of v i t a l s t a t i s t i c s . In 1855, reform of l o c a l government i n London allowed the appointment of forty-eight medical o f f i c e r s . By 1857, the Lancet calculated upwards of f i f t e e n -thousand sanitary nuisances had been removed. "They caught a l l kinds of stench, and snares and a l l sorts of nuisance." However, i t was not u n t i l 1872, by l e g i s l a t i o n , that Medical Health O f f i c e r s were appointed to 1400 other areas i n the country. The Public Health Act of 1875 marked the high water mark of environmental s a n i t a t i o n as a n a t i o n a l l y com-plete system of health. Although c a r r i e d along by i t s own momentum for many years, towards the end of the century the sanitary idea began to be overtaken by a new concept, that of the i n d i v i d u a l and h i s personal needs. The great feats of s a n i t a t i o n had been accompanied by a s u b s t a n t i a l decline i n the death rate and e s p e c i a l l y that part due to i n f e c t i o u s diseases. The Medical Health O f f i c e r had no time for complacency. The infant m o r t a l i t y rate remained obstinately high. I t became cl e a r that environmental control wasn't enough and that services directed towards the needs of vulnerable groups were necessary. By the beginning of t h i s century, a rudimentary health v i s i t i n g and c h i l d welfare c l i n i c s e rvice was gradually being introduced to improve infant care. The 1902 Midwives Act l a i d the foundation for the regulation and control of midwifery with a view to reducing maternal m o r t a l i t y . I t was not u n t i l the 1930's that the Maternal & Child Health services under the Medical Health O f f i c e r reached f u l l development. G. Bernard Shaw wrote to Sykes, Medical Health O f f i c e r for St. Pancras, i n 1903, about concern f o r lack of involvement of the Medical Health O f f i c e r i n 13 schools. Sykes was a knowledgeable Medical Health O f f i c e r and had written "State remedies cannot be applied i n advance of public opinion, and t h i s i s slow to move. The education of a vast community i s perhaps the most d i f f i c u l t task to f a l l to sa n i t a r i a n s . Persuading the u n s c i e n t i f i c mind to reason l o g i c -a l l y , even a f t e r possession of the f a c t s , i s not a l i g h t task. To rouse i t to take acti o n , even when convinced, and to overcome prejudice, requires a pro-digious e f f o r t . " Probably, t h i s i s a very sound statement on the d i f f i c u l t i e s of health education. Sykes responded to Shaw with a comprehensive job d e s c r i p t i o n f o r the Medical Health O f f i c e r i n schools and encouraged Medical Health O f f i c e r s to be involved i n examination of school ch i l d r e n . The school medical service was i n -troduced i n 1907. The f i r s t World War highlighted two grave sickness problems - venereal disease and tuberculosis. L e g i s l a t i o n and b r i s k organization f a c i l i t a t e d the rapid development by public health departments of venereal disease c l i n i c s ervice. A whole new service with s t a f f and s a n i t o r i a beds was developed for tuberculosis. As knowledge of i n f e c t i o u s disease increased so did n o t i f i c a t i o n , immunization, i s o l a t i o n and d i s i n f e c t i o n . By the 1930's, the Medical Health O f f i c e r was i n control of a wide range of personal and environmental health services c l o s e l y woven together. Preven-t i o n , diagnosis, treatment and r e h a b i l i t a t i o n - a l l came within h i s compass but prevention was uppermost i n his mind. (Wolfinden). The p r i n c i p l e s of s o c i a l medicine were put into d a i l y p r a c t i c e - housing and health, socialwork and tuberculosis, management of handicapped c h i l d r e n i n s p e c i a l schools, as w e l l as the previously mentioned development. 14 Following the second World War new duties were added - p r o v i s i o n of ambu-lances, health centres, home care and nursing, health education, and increased immunization r e s p o n s i b i l i t i e s . Mental health services developed following the B r i t i s h Mental Health Act of 1959. The U.K. S o c i a l Services Act of 1970 swallowed up mental health s e r v i c e s , home help, childrens work and services for the ch i l d r e n and the aged. The cleavage i s perpetuated today. The Medical Health O f f i c e r i n B r i t a i n , had a great deal of l e g i s l a t i v e power and r e s p o n s i b i l i t y . While purporting to be a s p e c i a l i s t i n preventive medicine he was a gen e r a l i s t . (Wolfinden 1974). The N.H.S., i n 1974, resulted i n the disappearance of the c l a s s i c a l Medica] Health O f f i c e r . He and h i s he i r s are now l a b e l l e d "community physicians" -some are employed i n a medical administrative capacity at r e g i o n a l , area and d i s t r i c t l e v e l s but as members of mul t i p r o f e s s i o n a l teams. Others are epide-miologists and other medical advisors of d i s t r i c t councils on environmental health matters and s o c i a l and educational services. The issue of r o l e and i d e n t i t y , under t h i s new system, continues to be one of the major problems that faces the s p e c i a l t y . About one-hundred out of the seven hundred consultant grade posts i n the s p e c i a l t y have a major managerial duty. The other six-hundred should play an advisory rather than an executive r o l e . They should p r a c t i c e the a r t of epidemiology and contribute towards the se t t i n g of objectives at each l e v e l of the service, measuring and evaluating need, demand and outcome. Epidemiology and medical s t a t i s t i c s should be the basic components of community medicine. Community medicine s p e c i a l i s t s c o n t r i -bute to the health of population groups i n a very d i r e c t way. The f a c t that the 15 e f f o r t s i n prevention, planning and evaluation have not yet received the atten-t i o n they deserve can be a t t r i b u t e d l a r g e l y to d i f f i c u l t i e s a r i s i n g from r e -organization and change of r o l e . In considering the new public health, Morris looks at the evolution of the community physician as epidemiologist, administrator of l o c a l medical services, community counsellor, p r o f e s s i o n a l man and p u b l i c servant. The t r a d i t i o n a l tasks of the Medical Health O f f i c e r as teacher, watchdog, and troublemaker, i n health, are being renewed and he w i l l have new duties i n the p r o v i s i o n of ser-vices as an i n t e g r a l resource of health protection. One of h i s main tools w i l l be knowledge, a contribution to s o c i a l p o l i c y at every l e v e l . He w i l l be able to combine s o c i a l science and medicine. In 1906 the society of Medical Health O f f i c e r s believed that the day of the Medical Health O f f i c e r would soon be over. It r e a l l y was only the end of the beginning. A s i m i l a r idea surfaced i n the 1940's. However, there continued then and now to be new needs r e s u l t i n g i n an evolving r o l e for the Medical Health O f f i c e r and h i s continued existence under whatever t i t l e or l a b e l . C l e a r l y , there has never been consensus as to what the r o l e of the Medical Health O f f i c e r i s i n B r i t a i n . There has been constant re-evaluation and r e -organization of the job d e s c r i p t i o n . Education of the Medical Health O f f i c e r i n U.K. This confusion has been engendered into the educational process as w e l l . The o r i g i n a l Medical Health O f f i c e r s i n the U.K. were simply q u a l i f i e d physi-cians, but as the f i e l d progressed a need f o r extra t r a i n i n g was recognized. The f i r s t Diploma i n Public Health (D.P.H.) began i n Dublin i n 1871 followed by 16 & Cambridge i n 1875. In 1888 a Medical Health O f f i c e r surveying a population greater than fifty-thousand population was required to have the D.P.H. q u a l i f i -cation, which took about a year to obtain. By 1922 i n B r i t a i n , every Medical Health O f f i c e r had to be so q u a l i f i e d . The q u a l i f i c a t i o n contained as much of the various elements required i n public health p r a c t i c e and administration as could be f i t into a one year period. The course of the r o l e changed. Community medicine represents a progressive combined development of medical administration and public health. As with any other d i s c i p l i n e the subject matter i s continuously changing. A doctor planning a career i n community medi-cine should obtain a varied c l i n i c a l experience, preferably both i n h o s p i t a l and i n general p r a c t i c e , before s t a r t i n g s p e c i f i c t r a i n i n g . This method ret a i n s f l e x i b i l i t y i n early t r a i n i n g i n case trainees should f e e l that the s p e c i a l t y had l e s s of an appeal than f e l t i n i t i a l l y . The Lancet disagrees with Heath & Perry's emphasis on f u l l time attendance at a u n i v e r s i t y course. Many doctors t r a i n i n g for other s p e c i a l t i e s have to combine the service and academic aspects of the job, and indeed separation of these i s one of the major c r i t i c i s m s that has been l e v e l l e d against community medicine i n the past. The Lancet also disagrees with t h e i r suggestion of crea-t i o n of a s u b s p e c i a l i s t grade. The Lancet f e l t that only by giving proper place to epidemiology can community medicine a t t r a c t the best young minds, and only t h i s d i s c i p l i n e can reveal the impact of the s p e c i a l t y on health. Tomorrow's community physician i n the U.K. w i l l continue to administer l o c a l health services but can only succeed by b u i l d i n g an e f f e c t i v e i n t e l l i g e n c e system. Local epidemiology should be the frame for c l i n i c a l p r a c t i c e and team-work, provide tools f o r management and improvement of services and more analysis 17 and t r i a l s . A f t e r twenty years one of the sadder disappointments of the N.H.S. i s the poverty at the l o c a l l e v e l of i t s learning resources. Without knowledge there can be no planning to " r e a l i z e an image of the future" - no r a t i o n a l i t y . The unique con t r i b u t i o n of the community physician, and h i s passport to commu-n i t y leadership, w i l l be the information system he creates. Times have changed and complexities increased. In order to preserve a balance of resources and service a l l o c a t i o n between community and h o s p i t a l care, when the l a t t e r i s often said to be the more intense and dramatic of the two functions, i t was suggested that a diplomatic and highly trained doctor who has a knowledge of both f u n c t i o n a l parts, i s requiredT He would be a medical prac-t i t i o n e r e i t h e r with experience i n primary care or h o s p i t a l s who had subsequently undertaken an MSc or fellowship i n medical administration and sociology. Such a person would have a stake i n the future health service administration, which must cover and balance the whole spectrum of h o s p i t a l and community care and co-ordinate the f i e l d m u l t i - d i s c i p l i n a r y teams. He would be possessor of a combined d i s c i p l i n e . His t r a i n i n g and apprenticeship more than any other, would l i k e l y enable him to encompass the whole spectrum of community and patient care, as co-ordinator and f a c i l i t a t o r . The other "caring" professions such as nurses, s o c i a l workers and physiotherapists s t i l l generally deal with more l i m i -ted and s p e c i a l i z e d areas of human function and behaviour. Now, at l e a s t community medicine i s recognized as a s p e c i a l t y i n i t s own r i g h t . There has been continuous reassessment, re-evaluation, reorganization, and change i n the educational process. In t r a i n i n g the Medical Health O f f i c e r the obvious lack of consensus i n the organization of public health and the r o l e of the Medical Health O f f i c e r has been c a r r i e d into the educational model. 18 b. United States In the United States t h i s confusion has been c a r r i e d a step further. Ex-amination of the r o l e of the Medical Health O f f i c e r ( M i l l e r & Albers) i n d i c a t e s that registered nurses with a masters degree i n public health i n many cases have more t r a i n i n g and experience than physicians to function e f f e c t i v e l y i n th i s r o l e . I t i s suggested that, given current physician shortages, the change i n scope of public health p r a c t i c e , and the use of other professionals capable of f u l f i l l i n g t h i s r o l e , the s e l e c t i o n of physicians as l o c a l health o f f i c e r s should be viewed as only one of several a l t e r n a t i v e s . The e a r l i e s t documented instance of the use of a non-medical person as a l o c a l health o f f i c e r occurred i n 1873 i n New Jersey. A recent unpublished sur-vey of current practices among states, with regard to the use of non-physicians as Medical Health O f f i c e r s indicates that twenty-five states now use such per-sonnel, while twenty-five states s t i l l require by law or p o l i c y that a Medical Health O f f i c e r be a licenced physician. The i n a b i l i t y of many communities to r e c r u i t physicians to f i l l Medical Health O f f i c e r p o s i t i o n s i s an obvious s t i -mulus toward the use of other q u a l i f i e d personnel. Education of the Medical Health O f f i c e r i n the United States Nearly two-thirds of a l l health o f f i c e r s i n the United States have an M.P.H. (or s i m i l a r ) degree. About 23% have both an M.D. and M.P.H. (or s i m i l a r ) degree; about 9% have a bachelor degree, or no degree at a l l . The highest proportion of health o f f i c e r s who are physicians i s found i n the P a c i f i c and South A t l a n t i c regions (96.6% and 88.2% r e s p e c t i v e l y ) . Only about 25% of health o f f i c e r s i n the Mid A t l a n t i c and New England regions are physicians. About one-half of the health o f f i c e r s i n the South A t l a n t i c and 19 P a c i f i c regions have M.P.H. or s i m i l a r degrees. The growth and development of state and l o c a l health agencies w i l l depend 5> l a r g e l y upon the knowledge, s k i l l s and a t t i t u d e s of t h e i r p r o f e s s i o n a l s t a f f s Public Health Administrators should inform schools of public health about what knowledge they want trainees to acquire and what s k i l l s and a t t i t u d e s they want developed. Faculty members should encourage t h i s . Schools of public health have a r e s p o n s i b i l i t y to be among the leaders i n developing a t t i t u d e s towards patterns of program changes i n community health. Course content along problem centered l i n e s should recognize that administrative organization and management i n community health require the j o i n t e f f o r t s of g e n e r a l i s t s and s p e c i a l i s t s i n the medical and s o c i a l sciences. In performing hi s duties, the Medical Health O f f i c e r (physician) needs a deep understanding of human nature as well as formal t r a i n i n g i n administration and the health sciences. Leadership a b i l i t y i s e s s e n t i a l . I t ' s important that Medical Health O f f i c e r s have a broad educational back-ground as well as t r a i n i n g i n medicine and public health. A v a r i e t y of advanced programs are a v a i l a b l e to t r a i n a competent s p e c i a l i s t i n t h i s f i e l d . Recog-n i t i o n of t h i s competence through c e r t i f i c a t i o n by the American Board of Pre-ventive Medicine i s desirable. Residency t r a i n i n g and a degree i n public health or preventive medicine, to reach t h i s end, i s suggested. A sustained e f f o r t to-ward continuing education throughout the l i f e of the p r o f e s s i o n a l i s also essen-t i a l . The d i v e r i s t y and number of occupational t i t l e s i n which we f i n d graduates of schools of public health i s so great that no single-core curriculum can hope to prepare i n d i v i d u a l s adequately for p r a c t i c e i n the f i e l d . Public Health en-20 compasses d i r e c t medical care, the s e t t i n g of standards f o r c l i n i c a l and i n s -t i t u t i o n a l p r a c t i c e , the organization and administration of a v a r i e t y of commu-n i t y health programs and a multitude of other programs. At the same time the s e t t i n g f o r the p r a c t i c e of public health has changed. Kinney proposes redefining public health i n the United States as a d i s c i -p l i n e concerned with adequate functioning of the i n d i v i d u a l i n the p o l i t i c a l , s o c i a l and p h y s i c a l environment i n which conditions place him at a point i n time. To him i t i s a matter of applied "human ecology." Brotherston stated that public health tends to be detatched from the mainstream of c l i n i c a l medi-cine and the h o s p i t a l . Community medicine should act as a c e n t r a l f o c a l point <*3> for the growth of "human ecology." Medical Health O f f i c e r s i n the United States today are more l i k e l y to f i n d themselves involved i n p o l i t i c a l manipulation than b i o s t a t i s t i c a l manipulation; more l i k e l y to be c a l l e d to exercise t h e i r knowledge of s o l i d l o g i c than of s o l i d wastes; and f a r more l i k e l y to be confronted by the problem of the e p i -demiology of dissent than of diphtheria. A unique feature among students i n public health programs i s maturity and experience. Kinney f e e l s that few of the schools take advantage of the oppor-tunity to have these students with s p e c i a l i z e d s k i l l s p a r t i c i p a t e i n the pro-gram rather that s i t as passive r e c i p i e n t s . Students should teach as w e l l as learn, where the r e a l world of experience and the world of theory can i n t e r a c t i n such a way as to produce deeper understanding and greater commitment to a health philosophy based on i n d i v i d u a l d i g n i t y and s o c i e t a l good. 21 His f i n a l recommendations stress ceasing to educate nine month wonders -"pseudo - epidemiologic - b i o s t a t i s t i o - environmento - ad m i n i s t r a t o l o g i s t s " and to concentrate on the masters l e v e l students on an e c o l o g i c a l perspective and a phi l o s o p h i c a l base for the pr a c t i c e of public health. C u r r i c u l a should be r e s t r i c t e d to make maximum use of student experience and s k i l l s . Bring the community into the school through entry l e v e l t r a i n i n g and career ladder pro-grams i n the various public health content areas. F i n a l l y , (Mytinger, R.E.) emphasized the importance of attempting to r e -c r u i t recent, w e l l q u a l i f i e d graduates into public health and of providing them with opportunities for advanced public health t r a i n i n g . He found, i n a study, that the best general predictors of att i t u d e s re l a t e d to innovativeness were rank i n medical school graduating class and degrees held beyond the bachelor l e v e l . In the United States the extent of d i v e r s i f i c a t i o n i n def i n i n g the Medical Health O f f i c e r common r o l e has been c a r r i e d beyond the physician who t r a d i t i o n -a l l y has f i l l e d the r o l e . They include other r e l a t e d p r o f e s s i o n a l s . The educ-a t i o n a l process i s more confused again and admits i t s l i m i t a t i o n i n preparing the i n d i v i d u a l f o r the f i e l d and an i n a b i l i t y to develop a core curriculum. There i s n ' t a hint of consensus on the r o l e of the Medical Health O f f i c e r i n the United States which extends to in d e c i s i o n on who he should be. c. Canada The term Medical Health O f f i c e r s t i l l e x i s t s i n Canada and has not been o b l i t e r a t e d by change as i n B r i t a i n . Attempting to predict the r o l e of the Medical Health O f f i c e r might be described either as peering at a very murky cry-s t a l b a l l , or perhaps better looking at a kaleidoscope which never stops turning 22 and produces an ever changing p i c t u r e . Prevention i s far from the r e l a t i v e l y simple matter i t used to be, either primary or secondary. Changing behaviour ( l i f e s t y l e ) i s a very d i f f i c u l t area indeed. Unfortunately, there are very few well-proven methods of health education which can be r e a d i l y and inexpensively applied i n the community. Schwenger envisages two main r o l e s : I. The Medical Health O f f i c e r can concentrate on the r o l e described by Morris. This should s a t i s f y the more medically oriented Medical Health O f f i c e r who w i l l have a d d i t i o n a l c l i n i c a l , epidemiological and s t a t i s t i c a l t r a i n i n g . This r o l e has been described e s s e n t i a l l y as assessor (watchdog), monitor (troublemaker), and counsellor (teacher) or, I I . The Medical Health O f f i c e r can concentrate on the co-ordination of health services or even co-ordination of health and s o c i a l s e r v i c e s . He f e e l s i t i s u n r e a l i s t i c to expect the Medical Health O f f i c e r to do both jobs. More M.D.'s w i l l be f i l l i n g the job of community doctor and a smaller number w i l l f i n d the task of senior administrator to t h e i r l i k i n g . Medical schools should be prepared to t r a i n both types. Macintosh states "Medical Health O f f i c e r s do not have a defined r o l e . They do not have one general function which i s recognized by a l l , both within the corps of Medical Health O f f i c e r s , within the ranks of the medical profess-ion, by t h e i r employees and by the public at large, as the function at which they should aim to be good. Therefore they have no recognizable occupational goal." He also sees a gradual fading away of the Medical Health O f f i c e r as an obsolescent species. 23 Education of Medical Health O f f i c e r s In Canada In a 1960 questionnaire study concerning r e v i s i o n of the D.P.H. course i n ( S t ) Toronto, Le Riche contrasted several hundred public health programs? -^ He also found out what Toronto graduates thought of the curriculum for the D.P.H. and brought about considerable changes including the introduction of optional subjects. A D.P.H. r e v i s i o n committee was i n s t i t u t e d i n 1969 and ex-changed views on the future r o l e of the D.P.H. course. There was some d i f f i -c u l t y i n a r r i v i n g at consensus on future changes, i . e . , whether or not to include non-physicians i n the D.P.H. or to move towards an American type all-purpose M.P.HT"^  Perhaps too much was being crammed into a nine months course? In 1975, however, Schwenger states that the D.P.H. was to be transformed into an M.P.H. which would be open to a l l health professionals. Administration of e x i s t i n g l o c a l health agencies would no longer be the exclusive perogative of the physician but the posts would be open to competition among managers hav-ing a v a r i e t y of backgrounds. Teamwork would include respect for the profess-i o n a l autonomy of fellow health workers with leadership and charisma, not ex-elusive to the M.D. alone. The top l e v e l of q u a l i f i c a t i o n i n Canada i s the F.R.C.P. i n public health, or more recently i n community medicine. In 1972, Anderson found that of one-hundred and t h i r t y - t h r e e of these s p e c i a l i s t s , 38% were i n Ontario, and 29% i n B.C. However, 48% of a l l s p e c i a l i s t s who had obtained the c e r t i f i c a t e by exam-in a t i o n (not honorary) were i n B.C. C e r t i f i c a t i o n was c l e a r l y r e l a t e d to car-eer development i n that s i n g l e province where salary d i f f e r e n t i a l s and promotion favor the holder of the F.R.C.P. Elsewhere, the c e r t i f i c a t e was regarded merely 24 as a mark of excellence or c l i n i c a l competence. This s i t u a t i o n remains simi-l a r today i n B.C. The s p e c i a l t y t r a i n i n g requirements set out by the Royal College of Physi-cians and Surgeons of Canada (February 1978) for community medicine state the physician must have a basic knowledge of epidemiology and b i o s t a t i s t i c s , as well as an appropriate understanding of the p r i n c i p l e s of the s o c i a l sciences and of administration. The candidate i s expected to develop a f i e l d of concen-t r a t i o n from one of these f i v e areas: p u b l i c health, administration of health services, maternal and c h i l d health, epidemiology or c l i n i c a l preventive medi-cine. There are set out two streams of t r a i n i n g requirements of four years each to reach t h i s end. The Un i v e r s i t y of B r i t i s h Columbia o f f e r s an MSc (health services planning) which f u l f i l l s the above requirements, i n i t s public health option, for physi-cians. The program i s i n t e r d i s c i p l i n a r y i n approach and may be a good i n d i c a -t i o n of where education of the Medical Health O f f i c e r i n Canada i s going but there i s some uncertainty among the leaders as to whether t h i s type of t r a i n i n g i s the de s i r a b l e route for the Medical Health O f f i c e r . There are a v a r i e t y of routes one can pursue to become F.R.CP. e l i g i b l e , i n c l u d i n g c r e d i t f o r a year i n "any" c l i n i c a l s p e c i a l t y or c r e d i t f o r two years i n a family p r a c t i c e r e s i -dency. These numerous combinations of t r a i n i n g c e r t a i n l y i l l u s t r a t e a lack of agreement on a common t r a i n i n g route f o r the Medical Health O f f i c e r . The s i t u a t i o n i n Canada, i n general, i s perhaps only s l i g h t l y l e s s confus-ing than that i n the United States on the r o l e of the Medical Health O f f i c e r . 5. P r o v i n c i a l Variations i n Public Health and Medical Health O f f i c e r Roles We can now examine the major regions of Canada, attempting to f i n d a common 25 denominator. A l e t t e r was written to the other provinces, besides B.C., to r e -view public health organization and Medical Health O f f i c e r descriptions across the country. There was response from a l l areas, except Prince Edward Island and Nova Scotia, and these are summarized here where information was given. Newfoundland employs one f u l l - t i m e Medical Health O f f i c e r . A second Medi-c a l Health O f f i c e r i s employed by the International G r e n f e l l Association to look a f t e r public health programs i n Newfoundland and coastal Labrador. Public health programs are administered c e n t r a l l y from St. Johns and the Medical Health O f f i c e r i s occupied with administration of the p r o v i n c i a l immu-n i z a t i o n program, communicable disease control and epidemiology. Medical sup-port i s provided by the Medical Health O f f i c e r to public health nurses, health inspectors and the d i v i s i o n of N u t r i t i o n and Health Education throughout the province. Also employed are four f u l l - t i m e Child Health O f f i c e r s , (physicians with p e d i a t r i c q u a l i f i c a t i o n s or experience). Two are located i n St. Johns, one i n cen t r a l Newfoundland and one i n the west. They are occupied mainly with pre-school and school health assessments and with providing support to public health nurses i n these areas. The p r o v i n c i a l objective i s to organize four health regions and to s t a f f each with a Medical Health O f f i c e r , Child Health O f f i c e r , N u t r i t i o n i s t and Health Education person. Emphasis would be placed on immunization, c h i l d health and health promotion. The Medical Health O f f i c e r would be responsible f o r i n f o r -mation systems for h i s region and for planning programs to meet the needs New Brunswick has f i v e regional health d i s t r i c t s directed by Medical Health O f f i c e r s employed by the province. No discussion of the r o l e of the Medical 26 Health O f f i c e r was av a i l a b l e but program a c t i v i t i e s of the units included mat-ernal & c h i l d health, communicable disease c o n t r o l , public health nursing and inspection, home care, n u t r i t i o n , long term care, occupational therapy, health education, r a d i a t i o n and T.B. con t r o l . There was no information from Prince Edward Island but t h i s province i s i n the process of revamping i t s Health Care System placing the r e s p o n s i b i l i t y of health care on the public as well as health professionals and physicians. The emphasis w i l l be on health promotion and i l l n e s s prevention and health education to encourage i n d i v i d u a l s to take more r e s p o n s i b i l i t y f or t h e i r health. This i s i n the form of an experiment as l a i d out i n a "Discussion Paper" and would ob-vio u s l y r e s u l t i n a magnified r o l e f o r the community physician, (Medical Health O f f i c e r ) i f implemented. Quebec sent a s u b s t a n t i a l document, i n French. In 1973 t h i s document was developed i n tune with the Castonguay Report recommending the in t e g r a t i o n of public health with the general regime of d i s t r i b u t i o n of health and s o c i a l ser-v i c e s , including h o s p i t a l s and community health centres. It was f e l t that public health was s u f f e r i n g under two separate regimes of community care and h o s p i t a l care. Also, with the development of community health centres the whole thing should be pulled together. The plan would be implemented i n 31 ho s p i t a l s i n 12 regional d i s t r i c t s . It was decided to enlarge r e s p o n s i b i l i t i e s of the hosp i t a l s to house the d i v i s i o n of community health. This department would play a major r o l e i n the co-ordination of health and s o c i a l services i n commu-n i t y health centres, h o s p i t a l s and public health, thus bringing together a l l areas of prevention and treatment. In previous years, with separation, resource a l l o c a t i o n to public health had suffered. 27 The department of community health housed i n the h o s p i t a l s would be r e s -ponsible f o r the development of preventive services for the l o c a l community health centres, f o r development of physician and mental health programs r e f l e c t -ing the needs of the p a r t i c u l a r population, c o n t r o l of accidents and epidemics and to p a r t i c i p a t e i n health studies and to counsel the board of d i r e c t o r s of the h o s p i t a l and region on health matters. The community health d i v i s i o n would be under the d i r e c t i o n of a physician (Medical Health O f f i c e r ) trained i n medicine, epidemiology and administration. It would be desirable that the department of community health would be a f f i l i -i ated with a department of s o c i a l and preventive medicine of a u n i v e r s i t y . The Medical Health O f f i c e r would be responsible for the programs mentioned i n the previous paragraph and leadership i n co-ordinating and administering the pre-ventive and curative health needs of the community. This i s the route Quebec has been following The province of Ontario sent some guidelines respecting the Medical Health O f f i c e r . No d e t a i l s on job d e s c r i p t i o n were a v a i l a b l e . In general terms, they stated the function of the Medical Health O f f i c e r as the executive o f f i c e r of the Board of Health. He i s responsible f o r promotion and protection of the health of the p u b l i c , for keeping the board informed on health subjects, for implementing p o l i c i e s and d i r e c t i v e s of the board and f o r e f f e c t i v e management (3) of health unit or health department a c t i v i t i e s . Amalgamation of the departments of Health and Welfare occurred i n Manitoba, i n 1970. When th i s happened, the Medical Health O f f i c e r became a medical public health consultant to the public health nurses, s o c i a l workers and other s t a f f . The province i s divided into eight regions with a regional d i r e c t o r i n 28 charge and the Medical Health O f f i c e r i s no longer chief executive o f f i c e r of the units but acts as a consultant with some d i r e c t duties. In h i s r o l e desc-r i p t i o n , he i s described as a medical resource to the region and consultant i n public health and health care, p a r t i c i p a t i n g as a member of the regional manage-ment executive group. He i s to play an act i v e resource r o l e i n planning, de-l i v e r y and monitoring of community health programs of the department and commu-n i t y . He w i l l report to a regional d i r e c t o r on a day to day basis but w i l l be responsible and accountable f o r program standards and pro f e s s i o n a l competence to the executive d i r e c t o r of Public Health Services. Under general and s p e c i f i c r e s p o n s i b l i t i e s there are 27 points l i s t e d which cover v i r t u a l l y every area of community medicine and which stress the consultant and d i r e c t services r o l e rather than any administrative tasks. These appear to be the r e s p o n s i b i l i t y of the regional d i r e c t o r . Quebec, Alberta and Manitoba have included mental health and s o c i a l services i n t h e i r community medicine programs. Saskatchewan has a decentralized d e l i v e r y system f o r public health pro-grams whereby the province i s divided into ten regions, each with i t s own Medical Health O f f i c e r and s t a f f of health professionals. Local p a r t i c i p a t i o n i s encouraged through regional health boards which are advisory to the M i n i s t r y of Health. Regina, Saskatoon and the North have autonomous health programs re-l y i n g heavily on p r o v i n c i a l standards. They have had some problems i n r e c r u i t i n g physicians to f i l l the Medical Health O f f i c e r p o s i t i o n s . No r o l e descriptions were a v a i l a b l e but the p o s i t i o n here i s again a combination of administrative and d i r e c t s ervice functions. There have been several administrative studies done i n t e r n a l l y to t r y to im-prove the d e l i v e r y system for pu b l i c health programs. 29 Alberta enclosed a working paper on job descriptions for H e d i c a l Health O f f i c e r s and a p o s i t i o n paper on the future of the Medical Health O f f i c e r i n Alberta as a community physician. It was stressed that the Alberta Medical Health O f f i c e r s were opposed to many parts of the papersT -^ Dr. Schnee,an Alb e r t a public health physician,submitted p o l i c y papers to serve as a focus for discussions between the d i v i s i o n of l o c a l health services and health units, with the object of j o i n t l y e s t a b l i s h i n g a p o l i c y f o r the future r o l e of Medical Health O f f i c e r s i n Alberta. He f e l t that new challenges had emerged i n public health, chronic and l i f e s t y l e diseases, the aged, a l t e r n a t i v e s to high i n s t i t u t i o n a l costs and co-ordination of the m u l t i p l i c i t y of health and health re l a t e d s o c i a l services i n the community. These have replaced emphasis on communicable diseases, food and water, and s a n i t a t i o n and maternal & c h i l d health which are under better c o n t r o l . With the changes a r i s e s a r e l a t e d change i n the emphasis of the r o l e of the Medical Health O f f i c e r i n maintaining and promoting community health. The t r a d i t i o n a l roles of the Medical Health O f f i c e r were l e g i s l a t e d , medi-c a l and management. The medical r o l e of the Medical Health O f f i c e r i s indivudal and community with the community r o l e taking precedence. The Public Health Act and regula-tions prescribe the Medical Health O f f i c e r s " o f f i c e r r o l e . " (This i s the case i n a l l provinces). He f e l t there was no evidence to suggest that such powers be given to someone else . The management r o l e i s described as e x e r c i s i n g the authority and performing the duties of the board with respect to the administra-t i o n of the health u n i t . 30 The roles to be expanded by future Medical Health O f f i c e r s would be those of community health consultant, community health services co-ordinator, health researcher and planner. With an increased r o l e of the Medical Health O f f i c e r i n d i r e c t services or a community health r o l e , a reduced administrative r o l e i n the health unit would be expected. Schnee proposed that a l l administration be delegated to an admini-s t r a t o r and that health unit management committees be formed with the Medical Health O f f i c e r as medical d i r e c t o r , the administrator as executive d i r e c t o r and the nursing supervisor as nursing d i r e c t o r . A f u l l - t i m e Medical Health O f f i c e r should serve a population of 80,000 -120,000. Full-time people should be shared rather than encouraging part-time Medical Health O f f i c e r s . Rank ordered preference from most preferred creden-t i a l s f o r a Medical Health O f f i c e r would be: 1. c e r t i f i c a t i o n 2. masters l e v e l 3. diploma 4. M.D., without a d d i t i o n a l t r a i n i n g Also recommended was a program of i n - s e r v i c e education, emphasizing planning, s t a t i s t i c s , epidemiology, economics, community organization and community health and s o c i a l service co-ordination. The comprehensive "job d e s c r i p t i o n " of the Medical Health O f f i c e r includes the eight primary rol e s of Director, including input to administration, public r e l a t i o n s , and personnel management; O f f i c e r , with enforcement and a p p l i c a t i o n of l e g i s l a t i o n ; E p i d e m i o l o g i s t / S t a t i s t i c i a n ; Educator; Consultant to health unit s t a f f and community; Co-ordinator - health unit services; C l i n i c i a n ; Researcher/ 31 Planner - for health unit, community and department. Goals could be stated i n each area and measured by the c r i t e r i a of f u l f i l l m e n t of these goals. Schnee l i s t s four categories of Medical Health O f f i c e r : I. Director - f u l l - t i m e Medical Health O f f i c e r acting as health unit d i r e c t o r and community physician. I I . Medical Director - f u l l - t i m e Medical Health O f f i c e r acting as medical d i r e c t o r or health unit and community physician. In t h i s case leader-ship r e s p o n s i b i l i t i e s go to an executive d i r e c t o r . I I I . Consultant - no management r o l e but only o f f i c e r and consultant r o l e s . The other functions would be taken over by other p r o f e s s i o n a l s . IV. Part-time Medical Health O f f i c e r . Current Medical Health O f f i c e r s i n Saskatchewan and Albe r t a f u l f i l l , to some extent, most of the r e s p o n s i b i l i t i e s delineated i n category I which may be the most desirable. Category 4 i s the most undesirable. The categories leave considerable leeway i n d e l i v e r i n g p ublic health services. There i s no consensus as to a common r o l e i n t h i s instance or i n the case of the other provinces. Considerable v a r i a t i o n e x i s t s across the country. 6. Legal and Administrative P o s i t i o n of the Medical Health O f f i c e r  i n the B r i t i s h Columbia Public Health Service B r i t i s h Columbia i s composed of 18 health unit d i s t r i c t s with a Medical Health O f f i c e r i n a l l but two,(January 1979) who f u l f i l l s an administrative and service function, i n d e l i v e r y of community health services. Mental health and s o c i a l services are administered separately from community health programs. There are also four c i t y and one regional units which are autonomous but r e l y h e avily on p r o v i n c i a l standards and l e g i s l a t i o n f o r t h e i r program as we l l . Their Medical 32 Health O f f i c e r s meet every s i x months, with p r o v i n c i a l Medical Health O f f i c e r s , to discuss mutual problems and programs of i n t e r e s t . The top o f f i c i a l i n community programs i s at the Assistant Deputy Minis-t e r i a l l e v e l . Both he and h i s a s s i s t a n t are selected from among the Health O f f i c e r s t a f f . The Deputy Minister of Health i n B r i t i s h Columbia i s usually a physician. The Health Unit areas are mapped (see page 3 3 ) and each unit has several programs. The Medical Health O f f i c e r i s responsible f o r a l l programs. Public Health Nursing i s headed by a Nursing Supervisor with senior nurses i n various sub-offices. These nurses are involved i n a wide v a r i e t y of programs including the major ones of home care and long term care. The new long term care program has more autonomy than the others, having i t s own administrator i n each health u n i t , but t h i s person also comes under the Medical Health O f f i c e r . Public Health Nurses are also involved i n school health programs, V.D. and b i r t h c o n t r o l , c h i l d and adult health conferences, a l l immunizations, pre-natal and post-natal t r a i n i n g and counselling, health education, and a generally wide v a r i e t y of health unit functions to the community. They are g e n e r a l i s t s and are ass i s t e d i n t h e i r duties by other registered nurses. Public health inspection i s headed i n each health unit by a a Chief Public Health Inspector who comes under the Medical Health O f f i c e r . A Medical Health O f f i c e r i s appointed by government to be the chief health and sanitary o f f i c i a l for the municipality or union of m u n i c i p a l i t i e s to which he i s appointed and he has a l l powers and authority possessed by any Health O f f i c e r under the Health (51) ActV-^ In Health Inspection, the Medical Health O f f i c e r u sually delegates res-p o n s i b i l i t y of looking a f t e r the health and safety of the community environment 33 Health Unit Boundaries Greater Vancouver Vancouver Richmond Burnaby North Shore Greater V i c t o r i a Regional D i s t r i c t East Kootenay S e l k i r k West Kootenay North Okanagan South Okanagan South Central Upper Fraser Central Fraser Boundary Simon Fraser Coast G a r i b a l d i See B V Kimberley Cranbrook j c ^ l l i w a c k \ ) • ' ^ _ 13. Central Vancouver Island 14. Upper Island 15. Cariboo 16. Skeena 17. Peace River 18. Northern I n t e r i o r 34 to Health Inspectors. Other departments i n health units providing preventive health services to the community are dental hygiene, n u t r i t i o n , speech and hearing, environmental engineering, physiotherapy and health education. There i s an o f f i c e Supervisor i n each Health Unit who manages the c l e r i c a l s t a f f for a l l these departments. Staff i n each Health Unit can vary from 50-130 i n d i v i d u a l s . Local Boards of Health i n each municipality are the Council of the muni-c i p a l i t y but a municipality may by law j o i n with other m u n i c i p a l i t i e s to esta-b l i s h a Union Board of Health on which each municipality i s represented by school trustees and/or Council members. A member of a Regional D i s t r i c t c o u n c i l may also be on the Union Board. The Union Board exercises co-ordinating, super-vi s o r y , advisory and consultative functions i n the administration of health services i n the area within i t s j u r i s d i c t i o n , but has no l e g i s l a t i v e power. The Medical Health O f f i c e r i s secretary on the Union Board and most Health Units have these boards which belong c o l l e c t i v e l y to the Associated Boards of Health of B r i t i s h Columbia. Medical Health O f f i c e r s i n B r i t i s h Columbia l e g a l l y need only to be duly q u a l i f i e d p r a c t i t i o n e r s but a l l presently have further t r a i n i n g i n public health. Municipal councils usually accept p r o v i n c i a l appointment of Medical Health Off-i c e r s who are responsible for duties under the Municipal Act as well as Health Act. In the case where Regional D i s t r i c t s are responsible for administration of Health Services the Medical Health O f f i c e r assumes duties under t h i s Act as well. In B r i t i s h Columbia, as elsewhere, Medical Health O f f i c e r s are given c e r t a i n powers under the Health Act for c o n t r o l and abatement of nuisances which may constitute health hazards, for c o n t r o l of communicable diseases and for 35 inspection of f a c i l i t i e s and i n s t i t u t i o n s g i ving service to the public and where health hazards can develop. He has l e g a l authority ( l e g i s l a t e d o f f i c e r r o l e ) to see that the p r o v i n c i a l regulations i n these areas are adhered to pursuant to the Health Act of B r i t i s h Columbia. The l e g i s l a t e d O f f i c e r Role i s a l e g a l one and i s one of consensus, as de-fined i n the Health Act. Much of t h i s r o l e i s delegated to other s t a f f , e.g., Public Health Inspector. This area forms a r e l a t i v e l y small part of Administra-t i o n and Direct Services. It i s not explored i n d e t a i l here and, i n f a c t , could form the substance of a separate study. 36 CHAPTER I I I METHOD A survey questionnaire was mailed to a l l Medical Health O f f i c e r s i n B r i t i s h Columbia, to e s t a b l i s h l e v e l s of consensus on t h e i r r o l e d e s c r i p t i o n . There were twenty i n d i v i d u a l s involved i n t h i s survey, including f i f t e e n p r o v i n c i a l Medical Health O f f i c e r s , four c i t y Medical Health O f f i c e r s (Vancouver, Richmond, North and West Vancouver and Burnaby) and one regional Medical Health O f f i c e r ( V i c t o r i a and Southern Vancouver Island). The l a t t e r f i v e Medical Health O f f i c e r s run autonomous health programs which r e l y considerably on p r o v i n c i a l standards. There were s i x t y - f i v e questions i n the survey, which was divided into seven sections. These seven sections were designed to e l i c i t information on several areas concerned with r o l e d e s c r i p t i o n of the Medical Health O f f i c e r . The sections referred to were: 1. Personal Experience and Educational Background 2. Attitudes towards the Medical Health O f f i c e r Role 3. Workload and Setting 4. Administration 5. Direct Services 6. Relations with the Medical Community 7. New Directions Explanations of the contents preceded each section. Also included with the questionnaire was a request f o r a one week "time budget" (see Appendix). The Medical Health O f f i c e r s were asked to keep a record of t h e i r a c t i v i t i e s during any week and to c l a s s i f y them as to Direct Services or Administration and whether they were very u s e f u l , u seful or marginally 37 u s e f u l , i n t h e i r opinion. The questionnaire employed the 'double b a l l o t ' method of return whereby anonymity could be maintained. The document could be placed w i t h i n a blank envelope within an addressed envelope, on i t s return. This would allow one to determine which health units had not responded and needed reminders. An optional space was provided f o r signatures. The survey was mailed on A p r i l 28, 1978 and a reminder was given at 'Health O f f i c e r s Council' on May 11, 1978. A t h i r d reminder, by way of a per-sonal telephone c a l l to each non-respondent, was given on May 28, 1978. The f i n a l day for r e c e i v i n g questionnaires and time budgets was June 15, 1978. Following t h i s r e s u l t s were examined, referenced, tabulated, cross tabu-lated and compared with l i t e r a t u r e review findings where appropriate. Conclu-sions were drawn based upon the l e v e l of consensus among B r i t i s h Columbia Medi-c a l Health O f f i c e r s about t h e i r r o l e d e s c r i p t i o n . 38 CHAPTER IV ANALYSIS OF DATA In t h i s chapter, an e f f o r t w i l l be made to examine the l e v e l s of consensus among B r i t i s h Columbia Medical Health O f f i c e r s and to determine the extent to which t h i s may be used to define a common r o l e . 1. Description of Population The population under study i n t h i s case are twenty Medical Health O f f i c e r s i n the province of B r i t i s h Columbia. Seventeen responded to the questionnaire. Four of these work i n the large urban areas of V i c t o r i a , Vancouver, Burnaby and Richmond. The remainder are d i s t r i b u t e d throughout the province. Tables I, I I , and I I I describe the age d i s t r i b u t i o n , year of graduation f o r M.D. or equivalent and l e v e l of q u a l i f i c a t i o n of B r i t i s h Columbia Medical Health O f f i c e r s . TABLE I - AGE DISTRIBUTION OF B.C. M.H.O.s 60+ 50-59 40-49 3 5 5 30-39 3 TABLE II - YEAR OF GRADUATION 1940-1949 1950-1959 5 5 1960-1969 6 TABLE III - LEVEL OF QUALIFICATION DPH MSc Attempting FRCP FRCP 15 2 4 4 39 Twelve of seventeen received t h e i r undergraduate t r a i n i n g outside Canada. One q u a l i f i e d i n B r i t i s h Columbia. Four received a DPH from the U.K. and eleven received a DPH from Toronto; two pursued the MSc route at the Univ e r s i t y of B r i t i s h Columbia. 2. Levels of Consensus In the following discussion we w i l l examine the l e v e l s of consensus among the Medical Health O f f i c e r s by concentrating on: a. A l l o c a t i o n of E f f o r t b. Preparation f o r Medical Health O f f i c e r r o l e s c. Role of the Medical Health O f f i c e r in,the t o t a l medical community d. A t t i t u d e about Work and Setting e. New Directions i n Services a. A l l o c a t i o n of E f f o r t One measure of consensus among Medical Health O f f i c e r s would be the simi-l a r i t i e s between the actual time they spend i n administration and d i r e c t ser-v i c e s . Another measure would be the s i m i l a r i t i e s i n a t t i t u d e towards the kinds of services they should d e l i v e r . Perhaps the most c r i t i c a l issue surrounding the question of whether a r o l e e x i s t s has to do with whether the Medical Health O f f i c e r i s p r i m a r i l y an admini-s t r a t o r with a peripheral r o l e i n d i r e c t services or whether he i s pr i m a r i l y a community physician (provider of services) with only a peripheral r o l e i n admini-s t r a t i o n . Tables IV, V and VI o f f e r i n s i g h t s as to what Medical Health O f f i c e r s r e -gard as e s s e n t i a l administrative and d i r e c t service functions and how they a l l -ocate t h e i r time to administration and d i r e c t services. 40 TABLE IV - M.H.O . 1S DIVISION OF LABOUR WITH RESPECT TO PERCENT OF TIME ALLOCATED TO ADMINISTRATION % TIME NUMBER OF M.H.O.'S ' 0 - 10 11 - 20 1 21 - 30 31 - 40 1 41 - 50 4 51 - 60 3 61 - 70 4 71 - 80 81 - 90 91 - 100 4 TABLE V - ESSENTIAL ADMINISTRATIVE FUNCTIONS AS LISTED BY RESPONDENTS Es s e n t i a l Administrative Functions No. of P o s i t i v e Respondents Program Planning & Implementation 8 Meetings - Senior Staff Conferences 4 Reports for Union Board of Health 3 Evaluation of Program Outcomes 3 Leadership 3 Discussion of Staff Problems 3 Orientation of New Senior S t a f f 2 Delegation Duties 2 M i n i s t e r i a l Problems - Public Complaints 2 Decision Making 2 Medical Correspondence Between Health Unit & Physician & Hospital 2 Studying Relevant Information & New Directions 2 Negotiating Resources 1 Administrative C i r c u l a r s 1 Budget 1 41 TABLE VI - ESSENTIAL DIRECT SERVICES AS LISTED BY RESPONDENTS Es s e n t i a l Direct Services No. of P o s i t i v e M.H.O.'s Consultation to Hospitals & Physicians 12 Consultation to M u n i c i p a l i t i e s , Regional D i s t r i c t s and Groups Therein 7 V.D. and T.B. 5 Comm. Disease Control 5 Problem Solving for Staff 4 Advice to Public 4 Family Planning 3 N u t r i t i o n 2 Research 2 Media Statements 2 Environmental Programs 2 Comm. Care F a c i l i t i e s 2 Medical Consult. - Aid to Handicapped 2 Home Care 1 Epidemiology 1 Maternal & Child Health 1 Tables VII, VIII and IX explore marginally useful administrative functions, use of extra time ( i f a v a i l a b l e ) by Medical Health O f f i c e r s and those functions which Medical Health O f f i c e r s regard as lay administrative ones. TABLE VII - MARGINALLY USEFUL ADMINISTRATIVE FUNCTIONS -- THOSE FUNCTIONS WHICH MEDICAL HEALTH OFFICERS WOULD PREFER TO DELEGATE TO SOMEONE ELSE Marginally Useful Administrative Functions No. of P o s i t i v e Respondents Buildings & Space 8 Personnel Matters 7 O f f i c e Supervision 5 Government Cars 4 Equipment & Supplies 4 Signing Cheques & Reports & Forms 3 Answering Routine Letters 2 Low Order Planning 1 Union Business 1 Using Telpak 1 Meetings With Middle Management 1 42 TABLE VIII - HOW MEDICAL HEALTH OFFICERS WOULD USE EXTRA TIME IF IT WERE AVAILABLE Use of Extra Time No. Of P o s i t i v e Respondents Reading Journals & Education Upgrading 5 Program Planning 5 Meeting With Other Physicians and Community Groups 3 F i e l d Research 3 Appraisal of Community Needs & P r i o r i t i e s 3 P i l o t & Special Projects 2 Health Education 2 C l i n i c a l Work 2 Epidemiology 2 Writing A r t i c l e s For P u b l i c a t i o n 2 Staff Education 1 Program Evaluation 1 Golf & Contemplation 1 TABLE IX - LAY ADMINISTRATIVE FUNCTIONS - THOSE FUNCTIONS WHICH COULD BE DELEGATED TO A LAY ADMINISTRATOR Buildings Cars Personnel Matters Signing of Routine Documents Meetings Budget O f f i c e Administration Communication Expanded O f f i c e Supervision Co-ordination Health Education Media Releases Research Projects Evaluation Equipment & Supplies The following p r i n c i p a l findings emerge from the preceding tables and the information on the a l l o c a t i o n of e f f o r t by the province's Medical Health O f f i c e r s , i . In terms of the gross a l l o c a t i o n of time i t i s c l e a r that no p r a c t i c a l consensus i s evident from the percent time spent i n administrative areas as opposed to d i r e c t services. Eleven of the seventeen respondents spend between f o r t y to seventy percent of time i n administration. However, one al l o c a t e s l e s s than twenty percent of time to administration, while four 43 a l l o c a t e greater than ninety percent of time i n t h i s manner. i i . There i s l i t t l e agreement with regards to areas the Medical Health O f f i c e r believes to be e s s e n t i a l administrative functions. There was also no consensus with respect to marginally useful administra-t i v e functions. i i i . There were two apparent areas of consensus i n the d i r e c t services r o l e . Twelve out of f i f t e e n believed consultation to physicians and h o s p i t a l s i s necessary. (Two out of seventeen didn't understand the question.) Also, twelve out of f i f t e e n believe they weren't performing marginally u s e f u l d i r e c t services. i v . There i s no consensus about what constitutes lay administrative functions, but those l i s t e d correspond c l o s e l y with the l i s t of marginally useful administrative functions. Ten to f i f t e e n percent of time on the average i s spent performing these functions. Twelve out of seventeen f e l t any lay administrator should have a supportive and subordinate r o l e to the Medical Health O f f i c e r while eleven f e l t they would lose effectiveness i f they t o t a l l y relinquished the ad-m i n i s t r a t i v e r o l e . Thirteen f e l t they could use extra administrative help. b. Preparation for Medical Health O f f i c e r Role Another measure of agreement would concern the method of preparing an i n -d i v i d u a l to be a Medical Health O f f i c e r . The r o l e i t s e l f and the educational approach are c l o s e l y r e l a t e d . Consensus i n one generally would indi c a t e con-sensus i n the other because of dependency between the two v a r i a b l e s . 44 Tables X, XI and XII rate the various areas of t r a i n i n g with respect adequacy, relevancy and d e f i c i e n c i e s . TABLE X - RATING OF AREAS OF TRAINING Area of Training Rating by Number of M.H.O. 's Excellent Good F a i r Poor Total Administration 0 7 7 3 Epidemiology 2 6 7 2 Env. Engineering 2 9 3 3 Microbiology 6 7 1 3 Research & Planning 2 2 ' 8 5 Preventive Medicine 1 12 3 1 Public Health 3 7 5 2 Int. Health 1 3 6 7 Health Economics 1 1 8 7 So c i a l Medicine 0 6 7 4 Occ. Health 1 4 7 5 Mat. & Child Health 0 9 6 2 Lab. Procedures 2 '7 5 3 21 80 73 47 = 243 Percentage 9% 36% 33% 22% = 100% 45 TABLE XI - RELEVANCY TO JOBS OF AREAS OF TRAINING Area of Training Relevancy to Their Jobs By Number of M.H.O.'s D i r e c t l y Relevant Marginally Rel. Not Rel. Administration 16 1 Epidemiology 15 2 Env. Engineering 13 4 Microbiology 14 3 Research & Planning 11 4 2 Preventive Medicine 15 2 Public Health 17 Int. Health 4 11 1 Health Economics 1 13 3 Soc i a l Medicine 10 7 Occ. Health 7 9 1 Mat. & Chi l d Health 13 4 Lab Procedures 6 11 TABLE XII - DEFICIENT AREAS OF TRAINING Defi c i e n t Area Of Training Epidemiology Administration P.R. & P o l i t i c s & Health Educ. S o c i a l Medicine Microbiology Occ. Health Health Economics Medicolegal Env. Engineering Resident Training Rated By Number of M.H.O.'s 6 3 2 2 1 1 1 1 1 46 Tables XIII and XIV r e l a t e previous experience i n other f i e l d s by Medical Health O f f i c e r s and what they consider relevant experience for the Medical Health O f f i c e r . TABLE XIII - PREVIOUS EXPERIENCE RECOMMENDED .FOR. COMMUNITY MEDICINE WITH AVERAGE NUMBER OF YEARS RECOMMENDED Fi e l d s No. of Respondents Average No. of Recommending Years of Experience Recommended General Practice 15 2.5 P e d i a t r i c s 4 2.2 Internal Medicine 7 1.8 Psychiatry 1 0.5 TABLE XIV - EXPERIENCE IN OTHER FIELDS BY CURRENT M.H.O.'s F i e l d No. of Respondents Average No. Of Years Experience General P r a c t i c e 12 6 . 4 Internal Medicine 3 2.5 Surgery 2 3.5 Dermatology 2 4 T r o p i c a l Medicine 1 10 Occ. Medicine 1 5 (part-time) Emergency 1 1 Anesthesia & P e d i a t r i c s 1 5 The following p r i n c i p a l findings emerge from the tables and the information on preparation for the Medical Health O f f i c e r r o l e . i . There i s no consensus on the ra t i n g of areas of t r a i n i n g . i i . There i s consensus about relevancy to the job of areas of t r a i n i n g . Public health, administration, epidemiology, preventive medicine, microbiology, maternal and c h i l d health and environmental engineering 47 are considered the most relevant areas. Health Ecomonics was deemed the l e a s t relevant area. i i i . No agreement emerged on d e f i c i e n t areas of t r a i n i n g although epidemiology and administration were those most commonly mentioned. i v . F i f t e e n out of seventeen recommended Medical Health O f f i c e r s have a background of general p r a c t i c e f or 2 - 3 years. Twelve of t h i s group had such a background. v. Ten out of t h i r t e e n f e l t the F.R.C.P. should be obtained; four were undecided. There was no agreement on how to obtain the F.R.C.P. c. Role of the Medical Health O f f i c e r i n the T o t a l Medical Community In t h i s s e ction we w i l l be examining the degree of consensus amongst Medi-c a l Health O f f i c e r s i n r e l a t i o n s between themselves and the medical community at large. We w i l l be looking at ways each believe they can use the other more e f f e c t i v e l y and where there are areas of interference. Tables XVI and XVII query how c l i n i c i a n s could use Medical Health O f f i c e r s more e f f e c t i v e l y , where the health unit might be i n t e r f e r i n g with c l i n i c i a n s and how the Medical Health O f f i c e r might be used more e f f e c t i v e l y by c l i n i c i a n s . 48 TABLE XV - AREAS OF CLINICAL PRACTICE THAT COULD BE DEALT WITH IN THE HEALTH UNIT Areas for Health Unit No. of P o s i t i v e Respondents A l l Immunizations 7 A l l V.D. Treatment & Control 4 Home Care 3 Family Planning 3 N u t r i t i o n 2 Well Baby Care 2 Reporting of Food Poisoning 1 Communicable Diseases 2 Alcohol Problems 1 Long Term Care 1 Speech Therapy & Audiology 1 Smoking Cessation & L i f e s t y l e s 1 TABLE XVI - WHAT M.H.O.'S THINK CLINICIANS REGARD AS AREAS OF INTERFERENCE BY THE HEALTH UNIT Areas of Interference No. of P o s i t i v e Respondents Maternal & Child Care Advice 8 N u t r i t i o n & Counselling 2 Release of B i o l o g i c a l s & Lab. Services 2 Communicable Disease 2 Rheumatic Fever Program 1 Home & Long Term Care 1 Accidental Poisoning 1 Patient R e f e r r a l 1 Implications of Medical Competence 1 Vaccinations 1 49 TABLE XVII - HOW M.H.O.'S THINK CLINICIANS COULD USE THE M.H.O. MORE EFFECTIVELY Ways To Use The M.H.O. More E f f e c t i v e l y No.' of P o s i t i v e Respondents Reporting & Consultation About Comm. Diseases 8 Epidemiology Resource 2 Advice on T.B. & B.C. 2 Integration of Health Services 2 Health Care Planning 1 Bed U t i l i z a t i o n Committee 1 Hypertension Followup 1 N u t r i t i o n Counselling 1 Occupational Health Problems 1 S o c i a l & Family Problems 1 V i t a l S t a t i s t i c s I Research 1 By Treating Him As An Equal Even Though He Isn't "Saving L i v e s " 1 Findings i . The study indicated some agreement (t h i r t e e n out of seventeen) on the question that there were areas i n c l i n i c a l p r a c t i c e that should be dealt with i n the health u n i t , but Table XV indicates no consensus on the s p e c i f i c areas. i i . Thirteen out of seventeen claimed that c l i n i c i a n s could use the Medical Health O f f i c e r more e f f e c t i v e l y but Table XVIII i l l u s t r a t e s l i t t l e agreement as to how. i i i . There was no agreement on whether c l i n i c i a n s regard the health unit as i n t e r f e r i n g with t h e i r p r a c t i c e and no consensus as to s p e c i f i c areas of c o n f l i c t . i v . There was no consensus as to whether community medicine and the Medical Health O f f i c e r are too detatched from the mainstream of 50 c l i n i c a l medicine and the h o s p i t a l , v. F i f t e e n out of seventeen f e l t that the c l i n i c a l people regarded Medical Health O f f i c e r s and health units i n a favourable manner. d. Attitudes About Work and Setting All :s e v e n t e e n Medical Health O f f i c e r s claimed they were s a t i s f i e d with t h e i r jobs, would not wish to change posi t i o n s and found the work challenging and productive. F i f t e e n f e l t there was considerable freedom and autonomy i n de-f i n i n g t h e i r own " r o l e d e s c r i p t i o n . " There was no agreement on whether they spend most of t h e i r time doing what they believed was necessary i n the community. Thirteen out of seventeen f e l t they would not welcome more d i r e c t i o n from Health O f f i c e r ' s Council (twice annual meeting) i n defining t h e i r r o l e . e. New D i r e c t i o n s i n Service In t h i s section consensus on judgements about future r o l e s might give some idea about where the Medical Health O f f i c e r i n B r i t i s h Columbia i s going. Only seven Medical Health O f f i c e r s f e l t there were services i n which he should play an increasing r o l e . This i s not consensus. Thirteen out of seven-teen Medical Health O f f i c e r s f e l t there were current programs i n need of review. Tables XVIII and XIX deal with health unit programs i n need of review and diseases needing more attention by Medical Health O f f i c e r s . 51 TABLE XVIII - HEALTH UNIT PROGRAMS IN NEED OF CRITICAL REVIEW Programs In Need Of C r i t i c a l Review M.H.O.'S School.Health 7 Immunization 4 Maternal & Child Health 4 Prenatal Classes 3 Health Education 3 A l l Of Them 2 Communicable Disease 1 Lab. & Epid. Services 1 Telpak 1 Rheumatic Fever 1 Poison Control 1 Relations With Mental Health 1 Role of Union Board of Health 1 P.H.N, (nursing) 1 Environmental Health 1 Research 1 Administration of Health Department 1 O f f i c e Administration 1 TABLE XIX - DISEASES MERITING MORE ATTENTION BY M.H.O.'S AND THOSE WITH FEASIBLE PROGRAMS TO ATTACK THEM Diseases Meriting More Attention M.H.O.'S Feasible Programs From M.H.O.'s & Health Units By No. of M.H.O.'s Endocrine, N u t r i t i o n a l & Metabolic Disorders 10 8 Infectious & P a r a s i t i c Diseases 9 8 Neoplasms 8 6 Congenital & P e r i n a t a l 7 5 Hypertension & Hematological Disorders 6 6 Pregnancy, Ch i l d B i r t h , Puerperium 6 4 Circ u l a t o r y , Resp. Digestive and G - U 5 2 Neurological Disorders 2 0 Environmental Diseases 2 0 In d u s t r i a l Accidents 2 2 Highway Accidents 2 1 G e r i a t r i c s 1 1 52 Findings The l a s t three questions of the survey on which t h i s s e ction i s based were answered poorly. Three l e f t them a l l out and s i x l e f t out the l a s t question. i . There i s no agreement on what programs are i n need of review. i i . Diseases meriting greater attention were s p e c i f i c a l l y l i s t e d but there wasn't agreement on them, even then, or on f e a s i b l e programs to attack the s p e c i f i c diseases. i i i . Seven Medical Health O f f i c e r s only l i s t e d ten d i f f e r e n t services i n which the Medical Health O f f i c e r should play an increasing r o l e . There i s no consensus about where the Medical Health O f f i c e r i s going. 3. Levels of Consensus Among Sub Groups This discussion w i l l be l i m i t e d to attempting to f i n d agreement amongst "sub groups of the population of study i n an attempt to f i n d consensus. NEED FOR F.R.C.P. IN COMMUNITY MEDICINE TABLE XX - NEED FOR F.R.C.P. IN COMMUNITY MEDICINE AS DEPENDENT ON INDIVIDUAL LEVEL ACHIEVED Community Medicine M.H.O.'s Having F.R.C.P. Working On No F.R.C.P. F;R.C.P Need f o r r e t a i n i n g F.R.C.P. 9 1 No need f o r r e t a i n i n g F.R.C.P. 1 2 Undecided 1 2 1 Findings Nine out of eleven Medical Health O f f i c e r s having the F.R.C.P. f e l t i t 53 should be retained. None of three not having the F.R.C.P. or working on i t f e l t i t should be retained as a requirement for the Medical Health O f f i c e r s . A l l who f e l t that i t should be retained thought i t was necessary to r e -ta i n c r e d i b i l i t y and status with other physicians. Several mentioned the addi-t i o n a l f i n a n c i a l rewards from the a d d i t i o n a l q u a l i f i c a t i o n . This i s r a t i o n a l behaviour i n economic terms and consistent with the report of Anderson, D.O. i n 1972. There was no consensus on the best route to obtaining the F.R.C.P. Selection of Medical Health O f f i c e r s Candidates are selected mainly on the basis of assessment and interviews with the a s s i s t a n t deputy minister and his a s s i s t a n t . There was no consensus as to whether t h i s approach was s a t i s f a c t o r y . However, three Medical Health O f f i c e r s were not s a t i s f i e d with t h i s approach. These three only,are involved i n t h e i r health units with residency t r a i n i n g of Medical Health O f f i c e r s and are on the f a c u l t y at the Un i v e r s i t y of B r i t i s h Columbia. They f e l t a screen-ing committee should be involved, represented i n addi t i o n by f i e l d Medical Health O f f i c e r s and other f a c u l t y at the Univ e r s i t y of B r i t i s h Columbia. The previous two cross tabulations i l l u s t r a t e d some consensus i n the areas discussed. Several other attempts at cross tabulation, on the basis of age of Medical Health O f f i c e r s , education of Medical Health O f f i c e r s , geographic l o c a -t i o n and size of health unit, place of t r a i n i n g and background experience were employed looking for agreement i n various areas. No common patterns were e l i -c i t e d other than those mentioned. L i t t l e consensus was i l l u s t r a t e d i n t h i s data on d e f i n i t i o n of a common Medical Health O f f i c e r r o l e . 54 CHAPTER V SUMMARY AND RECOMMENDATIONS In this.study we have examined the l i t e r a t u r e of the countries of B r i t a i n , the United States and Canada looking f or consensus on the r o l e of the Medical Health O f f i c e r . The Canadian provinces have been looked at and the B r i t i s h Columbia Medical Health O f f i c e r examined i n d e t a i l . L i t t l e agreement has em-erged on the r o l e of the Medical Health O f f i c e r . Since there i s not agreement, should a p o l i c y c l a r i f y i n g the r o l e he deve-loped or should the B r i t i s h Columbia Medical Health O f f i c e r carry on as he has? He was found to be s a t i s f i e d with the job, which he regards as challenging and productive and, i n general, f e e l s he i s f u l f i l l i n g the needs of the commu-n i t y he serves. Considerable freedom was described i n defining h i s own r o l e and he preferred not to have t h i s tampered with by d i r e c t i o n from the c o l l e c t i v e group of Medical Health O f f i c e r s . There i s not any desire i n the group to develop a p o l i c y c l a r i f y i n g the ro l e . Job s a t i s f a c t i o n and personal freedom, possibly dependent on each other here are e s s e n t i a l components to e f f i c i e n t and e f f e c t i v e job functioning. The freedom i s i n h i b i t i n g development of a common r o l e but one can hardly argue i n favour of such a r o l e i f the needs of the community are being f u l f i l l e d under a d i v e r s i t y of rol e s . The freedom i s also i n d i v i d u a l i z i n g the r o l e and moulding i t i n terms of perceived c u l t u r a l and regional needs and demands. The l i k e l i h o o d of a cle a r e r r o l e emerging i n the 1980's i s remote. History to date has revealed a constant reorganization and re-evaluation of functions. This i s accelerated by rapid t e c h n i c a l , s o c i a l and p o l i t i c a l changes. The Medi-c a l Health O f f i c e r i s involved with too many areas of the s o c i a l m i l i e u to be 55 forced into a c l e a r e r paradigm. I would say that a clearer r o l e i n the f i e l d i s not r e a l l y necessary or desirable at t h i s time. Regional needs and personal preferences d i c t a t e the job d e s c r i p t i o n within the context of services provided by the province and the services the Medical Health O f f i c e r might administer i n a d d i t i o n to these. The personal freedom does leave more room for goal oriented innovation. I would disagree with Ian Macintosh who states Medical Health O f f i c e r s have "no recognizable occupational goal and w i l l fade away as an obsolescent species." In being a g e n e r a l i s t , each Medical Health O f f i c e r w i l l pick from the "pool" the required tools to f i t h i s own personal goals i n tune with regional needs, culture and t r a d i t i o n . There are c o n f l i c t i n g goals i n Health and t h i s i s perhaps more c l e a r l y engendered i n Community Health and the making of a Medical Health O f f i c e r . The general knowledge necessary i n a l l h i s working areas for understanding and planning strategy should be the goals of h i s t r a i n i n g and experience. This can mould an e f f i c i e n t and e f f e c t i v e planner who can d i r e c t these " c o n f l i c t i n g goals" into some kind of. organizational sense. A g e n e r a l i s t i s necessary for t h i s , not another stereotyped s p e c i a l i s t . Several areas where possible improvement could occur emerged. 1. Elimination of the marginally useful administrative functions (10-15% of time) by expansion of the O f f i c e Supervisor r o l e . I t was revealed that the B r i t i s h Columbia Medical Health O f f i c e r wants a lay administrator i n a supportive r o l e to perform the marginally useful admini-s t r a t i v e functions. He does not f e e l he would function as e f f e c t i v e l y i f he t o t a l l y relinquished h i s administrative r o l e to someone else. This i s i n oppo-s i t i o n to Schwenger who f e e l s that, two rol e s should evolve to f u l f i l l e i ther 56 an administrative or a d i r e c t service r o l e . The B r i t i s h Columbia Medical Health, O f f i c e r i s being trained to perform the majority of administrative tasks he wishes to r e t a i n and I would recommend th i s to continue. A lay administrator would have to be shared amongst three or more health units to absorb the marginally useful administrative jobs here and to remain busy. To maintain l o c a l personal contact and to be more c l o s e l y a l l i e d to these tasks I would suggest expansion of the r o l e of the O f f i c e Supervisor rather than creation of a new sophisticated lay administrator job d e s c r i p t i o n . 2. Re-evaluation of the public health educational program, p e r i o d i c a l l y , to improve d e f i c i e n t areas such as epidemiology and administration, at present and to diminish t r a i n i n g i n marginally relevant areas such as health economics. One of the weakest areas i n the U n i v e r s i t y of B r i t i s h Columbia MSc program i s one of the most important, as stressed by Heath and Parry, Morris and the Lancet. There i s presently one introductory course i n epidemiology i n the public health option which, by i t s e l f , i s simply too l i m i t e d to give the Medical Health O f f i c e r the epidemiological t r a i n i n g that the above writers f e e l i s necessary. I would agree that another more d e t a i l e d course i s needed. Morris has stated that the success of tomorrow's community physicians w i l l depend on an e f f e c t i v e i n t e l l i g e n c e system b u i l t up using epidemiologic t o o l s . F i f t e e n out of seventeen Medical Health O f f i c e r s f e l t that epidemiology was d i r e c t l y relevant to t h e i r positions while only eight rated t h e i r t r a i n i n g as good or better. Administration was f e l t to be d i r e c t l y relevant by sixteen Medical Health O f f i c e r s and Health Economics marginally relevant by the same number. The Uni-v e r s i t y of B r i t i s h Columbia course has three units of economics and h a l f of t h i s 57 for epidemiology. Administrative t r a i n i n g i s at l e a s t as l i m i t e d . Increased emphasis on epidemiology and administration and decreased emphasis on health economics i s recommended. 3. Re-evaluation of the s e l e c t i o n process f o r Medical Health O f f i c e r s to i n -clude the University of B r i t i s h Columbia f a c u l t y and f i e l d Medical Health Off-i c e r s as w e l l as the health department, i n screening candidates. This i s suggested because of the opinion of the only three Medical Health O f f i c e r s d i r e c t l y involved i n residency t r a i n i n g who support the concept. 4. Establishment of closer formal l i a i s o n with " c l i n i c a l medicine" by Medical Health O f f i c e r s , probably v i a the B r i t i s h Columbia Medical Association to expand the r o l e of "community physician" and further deteriorate t r a d i t i o n a l b a r r i e r s between the two physician groups, which have i n h i b i t e d progress i n community medicine. Medical Health O f f i c e r s f e e l they are regarded favourably by the medical community, at large. There was a f e e l i n g that the health unit and the Medical Health O f f i c e r could be used more e f f e c t i v e l y by the c l i n i c a l people but there was divided opinion on how to accomplish t h i s . I t would be reasonable to assume that there should be close r l i a i s o n be-tween Medical Health O f f i c e r s and c l i n i c a l physicians to enhance the breakdown of t r a d i t i o n a l b a r r i e r s between the two groups. This i s supported by Morris, Schwenger and B r i t i s h Columbia Medical Health O f f i c e r s . At the present time, there are only l o c a l contacts between Medical Health O f f i c e r s and p r a c t i t i o n e r s and some mutual projects through the B.C.M.A. Mutual formal discussions to d e l -ineate areas of r e s p o n s i b i l i t y , to determine the mechanism for using each other 58 more e f f e c t i v e l y and to improve organization of areas that can be dealt with more e f f i c i e n t l y and e f f e c t i v e l y i n the health unit and c l i n i c a l p r a c t i c e are necessary. For example, the costs of such things as "well baby care" i n c l i n i -c a l p r a c t i c e are astronomical. Can t h i s be done s o l e l y i n the health unit by Public Health Nurses with appropriate r e f e r r a l to c l i n i c i a n s ? Surely t h i s a t t i t u d e of "favourable regard with only occasional i n t e r f e r -ence" of c l i n i c i a n s towards Medical Health O f f i c e r s i s conducive to mutual d i s -cussions and c l a r i f i c a t i o n of i n d i v i d u a l areas of p r a c t i c e . The t r a d i t i o n a l b a r r i e r s revolving around interferences by "government physicians i n the realm of the private p r a c t i t i o n e r " have l i m i t e d the Medical Health O f f i c e r and I be-l i e v e the incentive l i e s with him to attack them at t h i s more favourable time. He has everything to gain i n expanding h i s r o l e of "community physician", es-p e c i a l l y i f these b a r r i e r s are lessening. Macintosh, i n the U.K., elucidated the nature of t h i s s p l i t which he f e l t was greatest i n the f i f t y years following the turn of the century. The fee for service private p r a c t i t i o n e r however does stand to lose income i f some of h i s functions are assumed by the health u n i t . One might expect that opposition to any Medical Health O f f i c e r interference would be greatest i n heavily doctored areas where the supply of physicians exeeds demand for services. At the other extreme where demand exceeds supply of services, r e l i e f of some services by health units might be welcomed by private physicians. Total r e s o l u -t i o n of t h i s problem i s n ' t l i k e l y u n t i l a l l physicians are s a l a r i e d . This topic could form the substance of further study. Requirements that new Medical Health O f f i c e r s obtain the F.R.C.P. q u a l i f i -cations to maintain c r e d i b i l i t y and equality with t h e i r c l i n i c a l peers, thus 59 f a c i l i t a t i n g mutual pursuits. Nine of eleven having the F.R.C.P. f e l t i t should be retained to r e t a i n c r e d i b i l i t y and status with other physicians. I believe i t would obviously f a c i l i t a t e dialogue between the groups, p a r t i c u l a r l y with s p e c i a l i s t c l i n i c a l physicians. I t i s a u n i v e r s a l l y accepted q u a l i f i c a t i o n i n t h i s country amongst physicians. In conclusion the Medical Health O f f i c e r i n B r i t i s h Columbia can be a key person i n the planning and d e l i v e r y of Health Services. Department p r i o r i t i e s and public opinion have played a part i n the course of t h i s r o l e but he has had much freedom to define h i s own d i r e c t i o n . Someone i s always needed who can look at the whole complex of health services and p u l l i t together i n an organizational sense. This i s the crux of the Medical Health O f f i c e r . He w i l l remain the "enforcer" of the Health Act and he w i l l keep h i s " c l i n i c a l eye" sharpened with hi s knowledge of such things as communicable diseases and environmental toxins. He can s t i l l see the " f o r e s t " , i n most cases, always to be h i s greatest asset and hopefully he w i l l never lose himself i n the "trees" as have so many of his c l i n i c a l colleagues. He w i l l continue to do h i s own thing, re-evaluating and reorganizing h i s r o l e from time to time. He has not, to date^reached consensus on t h i s r o l e and i t i s u n l i k e l y that he ever w i l l . It i s also u n l i k e l y , i n my opinion, that t h i s w i l l a l t e r h i s valuable ongoing contributions to Health Systems. 60 References Quoted By Number In L i t e r a t u r e Review 1. James, G., Public Health i n T r a n s i t i o n : The Health O f f i c e r ' s Viewpoint. Can. J. Pub. Hlth. 56(11): 474-82 Nov. 75. 2. Brockington, F., World Health, 3rd E d i t i o n , 1975. 3. Great B r i t a i n . , Consultative Council on Medical and A l l i e d Services (1920) Interim Report. London: H.M.S.O. 4. Morris, J.N., Tomorrow's Community Physician. Lancet, 18 Oct. 69, 811-16. 5. Schwenger, C., The Medical Health O f f i c e r - Past, Present, and Future. Can. J. Pub. Hlth., 66, Sept/Oct 1975, 416-17. 6. Navarro, V., A Cr i t i q u e of the Present and Proposed Strategies for Redi s t r i b u t i n g Resources i n The Health Sector and a Discussion of Alt e r n a -t i v e s . Medical Care 12: 721, 1975, 7. Ratstein, N.D., Berenberg, W,, Chalmers, T.C., C h i l d , C.G., Fishman, A.P., Perrin , E.B., Measuring the Quality of Medical Care, N. Eng. J . Med. 294: 582, 1976. 8. Abel-Smith, B., Value for Money i n Health Services, S.S. B u l l e t i n . 17. 1974. 9. M i l l e r , C.A., et a l , A Survey of Local Health Departments and t h e i r Directors, A.J.P.H., Oct. 77, 67(10): 931-9. 10. Jagdish, V., Community Medicine i n the B r i t i s h N.H.S,, A.J.P.H. Jan. 78, 68(1): 54-7. 11. M i n i s t r y of Health Report for 1967. On the State of Public Health. H.M.S.O. London 1967. 12. Royal Commission on Medical Education, H.M.S.O., London 1968. 13. Report of the Working Party on Medical Administration, (Charimnan R.B. Hunter) H.M.S.O., London 1972. 61 14. Grant, J.B., (1947) The Health Department and Medical Care; Certain Trends. Amer. J. Pub. Hlth., 37, 269-75. 15. Royal Society of Medicine Proceedings, The Medical O f f i c e r of Health (1847-1974) 67, Dec. 74, 1243-55. 16. E l l i o t , G.R.F., B.C. M i n i s t r y of Health. Lect. #4. Nov. 22, 1974. 17. Macintosh, J.M., Trends of Opinion about Public Health (1901-51) Oxford Press. 18. E d i t o r i a l : The Future of Community Medicine. Lancet. July 10, 1976, i 19. Warren, M.D., Acheson., R.M., Int. J. Epid,, 1973, 2, 371. 20. Higher Education f o r Public Health, Report of the Millbank Memorial Fund Commission. 1976. 21. Schwenger, C.W., Future Education of Physicians i n Public Health, Can. J. Pub. Hlth., 62: 1-2, Jan/Feb 71. 22. M i l l e r M.H., Albers, L.L., The Role of the Local Health O f f i c e r - Why Not a Nurse? Southern Med, J , , May 75. 23. Cameron, CM., The Role of the Local Health O f f i c e r , South, Med. J , , May 75. 24. Lichtenhan, R.L., The Past Present and Future of the Community Health Administrator. Oklahoma University Health Sciences Centre, Dec. 73. 25. The Society of Medical Health O f f i c e r s . Past Present and Future. Public Health 86(1): 27-42, Nov. 71. 26. Medical O f f i c e r of Health or Community Physician, Public Health 83(4): 153-6, May 69. 27. Heath, P., and Parry, W.H., Community Medicine: Has i t a Future? Lancet, July 10, 76. 62, 28. Morris, J.N,, Uses of Epidemiology, Edinburgh 1967,. 29. Lindon, R.L., The Future of the Public Health Doctor, Public Health 84(2): 71-94, Jan, 70. 30. A Time of T r i a l , Pub. Hlth., 88(1), 6-10, 31. Amos, F.B., Hilleboe, H.E., How Can We Improve the Teaching of Public Health? The View point of the Health O f f i c e r : 1955-65, A.J.P.H., 56(3), 508-12, Mar. 66. 32. Educational Q u a l i f i c a t i o n s of Phycician Directors of O f f i c a l Health Agencies, A.J.P.H., 59(2), 339-42, Feb. 69, 33. Kinney, J.R., Schools of Public Health - How Relevant to the 1970's? A.J.P.H., 60(11), 2086-89. 34. Clute, K. , Health and Society, 1973. U of T Press. 35. Mytinger, R.E., Barri e r s to Adoption of New Programs as Perceived by Local Health O f f i c e r s . Pub. Hlth. Rep., 82(2): 108-14, Feb. 67. 36. Leriche, W.H., Univ e r s i t y and Hospital Training of Public Health Physicians i n Canada. Ca. Med. Ass. J., 87, Dec. 22, 62. 1322-25. 37. Leriche, W.H., "The Curriculum Content of the Toronto Diploma i n Public Health." Can. J. Pub. Hlth., 53, 366, 1962. 38. Anderson, D.O., C e r t i f i c a t i o n i n Public Health - Training f o r Obsolescence. Can. J. Pub. Hlth., 63, 405-12. 39. Community Medicine. Specialty Training Requirements, R.C.P.S. of C , Feb. 76. 40. Information Brochure f o r M.Sc. (Health Services Planning) Dept. of Hlth, Care and Epidemiology, U.B.C., Jan. 78. 63 41. Severs, D., Chief M.H.O., Dept. of Hlth., Newfoundland and Labrador 78. * 42. Wyllie, H.W., Ass't. Dep. Minister of Health, New Brunswick 78. * 43. Orientations Generales en Sante. Communautaire Ministere des A f f a i r e s Sociales. Quebec. Oct. 73. 44. Martin, G.L., Chief M.H.O., Min i s t r y of Health, Ontario 78. * 45. French, W.G., Executive Director, Public Health, Dept. of Health and Soc i a l Development, Manitoba 78. * 46. Derrick, M.B., Dep. Minister of Health, Saskatchewan 78. *' 47. Schnees, P., A l t e r n a t i v e Job Descriptions of Future M.H.O.'s.' A Working Paper Prepared for Alberta Dept. of So c i a l Services and Community Health. July 76. 48. Schnee, P., P o s i t i o n Paper on the Future of the M.H.O. i n Alberta as Community Physician. Nov. 76. 49. Webb, M.L., Director General, Local Health Services, Alberta 1978. * 50. Rolfe, E., P.E.I. Discussion Paper Places R e p o n s i b i l i t y for Health Services on Public Health Professionals and Physicians. CM.A.J., A p r i l 8, 78, 118, 829-30. 51. Health Act of B r i t i s h Columbia, Chapter 170, 1960. 52. Mcintosh, Ian D., On Having Been a Medical O f f i c e r of Health. Can. J. Pub. Hlth. 69(5) .375-77 Sept/Oct 78. 53. Mcintosh, Ian D., The Canadian Medical O f f i c e r of Health: A Look at His Future. Can. J. Pub. Hlth. 69(5) 355-59 Sept/Oct 78. Personal Communications 64 References Read But Not Cited Mackenzie, R. Alec, The Time Trap, McGraw-Hill Paperbacks 1972. Morgan R.W. Prospects f o r Preventive Medicine, Ont. Economic Council 1977. Abramson, J.H., Survey Methods i n Community Medicine, C h u r c h i l l - L i v i n g s t o n e 1974. B i l l e t , R.O., Preparing Thesis and other Typed Manuscripts, L i t t l e f i e l d Adams & Co. B a t t i s t e l l a , R.M., Chester, T.E., Role of Management i n Health Services i n B r i t a i n and the United States, Lancet, Mar. 18/72. Medical O f f i c e r of Health, From a s p e c i a l correspondent, B.M.J., 1972, 4, 166-167. The Part-time Medical O f f i c e r of Health, Alan Tomlinson, Can. J. Pub. Hlth. Mar/Apr 71, 164. Nisbet, E.R., Medical O f f i c e r of Health, Hlth. B u l l e t i n , 33, 164, Jan. 75. Robertson, J.S., The D i s t r i c t Community Physician, Pub. Hlth., 89(4), 124-5, May 1975. BIBLIOGRAPHY APPENDIX 65, MEDICAL HEALTH OFFICER QUESTIONNAIRE Please note: The enclosed questionnaire has been designed to s o l i c i t information from you, i n an attempt to c l a r i f y the current s i t u a t i o n . Much work has gone into i t to minimize the time needed to answer i t . The "double b a l l o t " method of return can be used to maintain anonymity by placing the question-naire within a blank envelope and placing t h i s within an addressed envelope. I w i l l receive the blank envelope from the secretary who can check who has responded. An optional space i s provided at the end of the questionnaire i f you wish to give your name. 66 TO: A l l Medical Health O f f i c e r s i n B.C. RE: The "Role of the Medical Health O f f i c e r (M.H.O.) i n B.C." As you know, despite the growing concern with the r o l e of the M.H.O. i n Canada, there i s l i t t l e information on the t o p i c . In l i g h t of t h i s , I have decided to do a thesis on "The Role of the M.H.O. i n B.C." as a part of the requirements for the MSc. (health services planning). I am hoping t h i s information may be of some future use i n terms of se l e c -t i o n , education, o r g i n i z a t i o n of functions, d e l i n e a t i o n of "job d e s c r i p t i o n " and d e f i n i t i o n of the M.H.O. As you w i l l discover i n the questionnaire I am looking at i n d i v i d u a l back-grounds and examining the job d e s c r i p t i o n i n terms of att i t u d e s concerning d i r e c t services and administration. Also I w i l l be reviewing the l i t e r a t u r e i n order to examine what the r o l e of the M.H.O. elsewhere, and w i l l attempt to cor r e l a t e t h i s with the data here. As usual with these projects, the time element i s important. I am attempt-ing to do most of t h i s work p r i o r to assuming my duties as M.H.O. i n the Cariboo on July 1st, 1978. An answer within the next two to three weeks would be most h e l p f u l i n allowing me to get t h i s together within the time frame. Thank you for your consideration and for any help you can give. Yours s i n c e r e l y , QUESTIONNAIRE A. Personal Experience arid Educational Background An i n d i v i d u a l ' s background, t r a i n i n g and experience usually have a strong bearing on how he approaches h i s work. Therefore, i n t h i s section, we would l i k e to obtain some information on these f a c t o r s . 1. Your age ( ) 30-39 ( ) 40-49 ( ) 50-59 ( ) 60+ 2. Where did you receive your M.D. or equivalent? ( ) B r i t i s h Columbia. ( ) Canada, other than B.C. Specify ( ) Outside Canada. Specify 3. In what year did you graduate? ( ) ( ) ( ) ( ) 4. Where did you receive your t r a i n i n g i n Community Medicine? (Public Health and Preventive Medicine) ( ) B r i t i s h Columbia• ( ) Canada, other than B.C. Specify ( ) Outside Canada. Specify 5. What i s your l e v e l of q u a l i f i c a t i o n i n Community Medicine? ( ) D.P.H., or equivalent-( ) M.P.H., MSc, or equivalent, ( ) F.R.C.P. ( ) Other. Specify 6. Are you s t i l l working on further q u a l i f i c a t i o n s i n t h i s f i e l d ? ^ ( ) Yes ( ) No 7. If yes, please specify 68 8. How many years of experience did you have i n Community Medicine p r i o r to becoming an M.H.O. i n B.C.? ( ) ( ) Years 9. How many years of experience have you had as an M.H.O. i n B.C.? ( ) ( ) Years .... as an M.H.O. outside B.C. ( ) ( ) Years 10. How many years of experience have you had i n other f i e l d s of medicine? ( ) ( ) Years Specify f i e l d s and years 11. Could you indicate roughly how many years, i n t o t a l , you expect to prac t i c e as an M.H.O.? ( ) ( ) Years ( ) No B. A t t i t u d e Towards The Medical Health Offjeer Role In t h i s section we would l i k e to obtain your views about your present r o l e , and to indica t e how you f e e l about the current approaches for r e c r u i t i n g M.H.O. candidates and for t r a i n i n g them. This w i l l give some i n d i c a t i o n about the present function of the M.H.O. 12. Pick the statement which best describes the way you f e e l towards your present f i e l d as an M.H.O. a. ( ) I am s a t i s f i e d and would not want to change f i e l d s . b. ( ) I am not r e a l l y s a t i s f i e d but have not attempted to change f i e l d s . c. ( ) I am not s a t i s f i e d and have attempted to change f i e l d s . If you selected 12a., please go on to question 16. If you selected b. or c , please continue 69 13. Why are you not s a t i s f i e d ? 14. If you were s t a r t i n g over again to choose a career, which of the following statements comes close s t to i n d i c a t i n g your choice? ( ) I would choose community medicine but i n another area besides being an M.H.O. ( ) I would not choose community medicine. ( ) I don't know. 15. If you did not choose community medicine, can you i n d i c a t e what you might have chosen? 16. Generally speaking, how would you rate the adequacy of your t r a i n i n g and educational program for the p o s i t i o n of M.H.O.? ( ) Excellent ( ) Good ( ) F a i r ( ) Poor ( ) Undecided 17. With respect to each p a r t i c u l a r area of t r a i n i n g that you received how would you rate? Excellent Good F a i r Poor Undecided Administration Epidemiology Environmental Engineering Microbiology Research & Planning Preventive Medicine Public Health International Health Health Economics Soci a l Medicine Occupational Health Maternal & Child Health Laboratory Procedures Other (Specify) 70. 18. Please rate your areas of t r a i n i n g i n terms of t h e i r relevance to your present p o s i t i o n . D i r e c t l y Marginally Not Relevant Relevant Relevant Administration Epidemiology Microbiology Environmental Engineering Research & Planning Preventive Medicine Public Health International Health Health Economics Soci a l Medicine Occupational Health Maternal & C h i l d Health Laboratory Procedures Other (Specify) 19. In your opinion, did your t r a i n i n g program not include some areas you needed and what were they? 20. In the l i g h t of your t r a i n i n g and work experience, i s the present approach for s e l e c t i n g prospective M.H.O.'s, producing candidates who, you f e e l , have the kinds of backgrounds and personal q u a l i f i c a t i o n s f or f u l f i l l i n g t h i s role? ( ) Yes ( ) No ( ) Undecided 21. Are you s a t i s f i e d with the current methods of r e c r u i t i n g candidates? ( ) Yes ( ) No ( ) Undecided If your answer i s "Yes" or "Undecided" please go to question #24. If your answer i s "No", please continue. 71 22. Why are you not s a t i s f i e d ? 23. How would you ammend the present method? ( ) Don't know. ( ) Specify 24. Do you f e e l that applicants should be trained or experienced i n other f i e l d s of medicine? ^ ( ) Yes ( ) No ( ) Undecided 25. If you answered "Yes", could you indic a t e what you think are the relevant f i e l d s and recommended minimum number of years experience required i n any one of them? 26. Recognizing the F.R.C.P. as the f u l l s p e c i a l t y q u a l i f i c a t i o n i n community medicine, which approach would you recommend for achieving i t ? ( ) D.P.H. & assistant d i r e c t o r (Trainee). ( ) M.P.H. or MSc. & assistant d i r e c t o r (Trainee). ( ) Other (specify) ( ) Undecided 27. In your view, i s there a need for a c l i n i c a l s p e c i a l t y , or F.R.C.P., at a l l , i n t h i s f i e l d ? ) Yes ( ) No ( ) Undecided 22: 28. If "Yes", could you indicate why? C. Workload & Setting We would l i k e to f i n d out about a t y p i c a l week and what you f e e l about i t s relevance to the community. This section w i l l reveal some ideas about your job effectiveness. 29. Given that the set workload i s 37 hours, how many hours do you work i n a t y p i c a l week. ( ) ( ) Hours 30. Generally speaking, do you f i n d the work challenging and productive? ( ) Yes ( ) No ( ) Undecided 31. What kind of freedom do you have i n d e f i n i n g your own "job d e s c r i p t i o n ? " ( ) Considerable ( ) Limited ( ) None 32. Would you welcome more d i r e c t i o n , i n defining your r o l e , from Health O f f i c e r s ' Council? ) Yes ( ) No ( ) Undecided 33. If "Yes", i n what areas would you f i n d d i r e c t i o n most useful? 34. Pick the following statement which i s most c h a r a c t e r i s t i c of how you f e e l your time i s spent f u l f i l l i n g the needs of the community i n community medicine? ( ) Most of my time i s spent doing what I believe needs to be done i n the community. 73 ( ) F i f t y to seventy percent of my time i s spent doing what I believe needs to be done i n the community. ( ) Some of my time i s spent doing what I believe needs to be done i n the community. ( ) Seldom i s any of my time spent doing what I bel i e v e needs to be done i n the community. D. Administration Here we w i l l explore administrative tasks and t h e i r importance to you i n f u l f i l l i n g your r o l e i n the community. 35. What approximate percentage of time do you spend i n Administration ( ) ( ) % Direct Services ( ) ( ) % 100 % 36. In your view, what are the e s s e n t i a l administrative functions f or you? 37. Are you currently performing any administrative functions which you f e e l are marginally important? ) Yes ( ) No ( ) Undecided 38. If "Yes", what are these functions and what percentage of t o t a l time do you spend doing them? (approximately) (Please ensure your estimate i s r e a l i s t i c i n terms of your estimate i n question #5). 74 38. (continued) Marginally Relevant Administrative Tasks Percentage of Time 39. If you had extra time what would you do with i t ? 40. Pick the statement which best represents your view about the time you spend i n administration. ( ) I am t o t a l l y s a t i s f i e d with the amount of time spent i n administration. ( ) I am reasonably s a t i s f i e d . ( ) I am somewhat d i s s a t i s f i e d . ( ) I am very d i s s a t i s f i e d . 41. Although M.H.O.s are now t o t a l l y responsible for administering t h e i r u n i t , some i n the f i e l d believe that there may be a place i n the health unit for a "lay administrator"; others disagree. Do you f e e l there i s room for one i n your unit? ( ) Yes ( ) No ( ) Undecided If you answered "No" or "Undecided", proceed to question #44. If you answered "Yes", please continue... 75 42. What administrative or other functions do you f e e l they could assume? 43. Pick the statement which best represents your opinion about the r o l e of a "lay administrator" i n r e l a t i o n to yourself. ( ) Supportive & Subordinate r o l e . ( ) D i v i s i o n of labour/Division of c o n t r o l . ( ) Superior and d i r e c t i n g r o l e . 44. Can the M.H.O. function equally e f f e c t i v e l y i f he relinquishes h i s p o s i t i o n as administrator of the health unit? ( ) Yes ( ) No E. Direct Services The approaches which the M.H.O. takes i n meeting the needs of t h e i r p a r t i c u l a r communities w i l l vary depending on the l o c a t i o n and si z e of the area. We w i l l examine these services and how you f e e l about t h e i r worth i n terms of your p o s i t i o n . 45. In your opinion, what are the e s s e n t i a l " d i r e c t s e r v i c e s " functions you f u l f i l l ? 46. Are you currently performing any "d i r e c t s e r v i c e " functions which you f e e l are marginally important? ^ ( ) Yes ( ) No ( ) Undecided 47. If "Yes", what are these functions and what percent of t o t a l time (approximately) do you spend doing them? 48. Do you f e e l that i t i s worth the time and e f f o r t for the M.H.O.s to gain further expertise i n p a r t i c u l a r areas, (eg. epidemiology) so they might act as resource people for each other and others i n the province? ( ) Yes ( ) No ( ) Undecided F. Relations With The Medical Community One area which i s obviously c u r c i a l for the M.H.O. i s the q u a l i t y of th e i r r e l a t i o n s h i p with t h e i r colleagues i n the medical community. In t h i s section we w i l l pursue your general views about how the M.H.O. should r e l a t e to the medical community, and vise-versa. 49. Do you f e e l that community medicine and the M.H.O. are too detached from the mainstream of c l i n i c a l medicine and the hospital? ( ) Yes ( ) No ( ) Undecided 50. In your view, are there areas presently dealt with i n c l i n i c a l p r a c t i c e which should be dealt with i n the health unit? ^ , ( ) Yes ( ) No ( ) Undecided 51. If "Yes", what are these areas? n 52, Do you think the " C l i n i c i a n s " regard the health unit as i n t e r f e r i n g with some areas of t h e i r practice? ( ) Frequently ( ) Occasionally ( ) Seldom ( ) Never 53. What are these areas of interference, i f any? 54. How do you f e e l the " C l i n i c i a n s " regard your function with respect to them and the community at large? ( ) Very Favourably ( ) Favourably ( ) Not Favourably 55. Could " C l i n i c i a n s " , i n your view, use the M.H.O. more e f f e c t i v e l y ? ^ ( ) Yes ( ) No ( ) Undecided 56. If "Yes", could you indica t e i n what possible ways? G. New Directions In t h i s , the f i n a l section, we would l i k e to determine your views about changes i n the r o l e of the M.H.O.s i n community medicine. We would l i k e your opinions on the need of reviewing some of the current d i r e c t service programs, and we would l i k e to know i f any areas of d i r e c t services need expanding. 57. Do you consider the M.H.O. a health planner and researcher? ) Yes ( ) No ( ) Undecided 58. If "Yes", i s he being trained e f f e c t i v e l y for t h i s role? ( ) Yes ( ) No ( ) Undecided 78 59. Are there any d i r e c t services i n which you f e e l the M.H.O. should play a greater role? ( ) Yes ( ) No ( ) Undecided 60. If "Yes", what are these services and how can he play a role? 61. In your opinion, are there any current programs which are i n need of c r i t i c a l review? l ( ) Yes ( ) No ( ) Undecided 62. If "Yes", what are these programs? 63. In the following l i s t , are there any diseases which, i n your opinion, merit greater attention from health units and M.H.O.s? (Please c i r c l e the diseases which merit greater a t t e n t i o n ) . 1. Infections and p a r a s i t i c diseases. 2. Neoplasms. 3. Endocrine, n u t r i t i o n a l and metabolic diseases, 4. Hypertension and hematologic disorders. 5. Neurologic disorders. 6. C i r c u l a t o r y , r e s p i r a t o r y , d i g e s t i v e and G-U problems, 7. Pregnancy, c h i l d b i r t h and puerperium, 7-9 63. (continued) 8. Skin and musculo s k e l e t a l disorders. 9. Congenital and p e r i n a t a l disorders. 10. Other (Specify) 64. Are there any f e a s i b l e programs which you are not now using that could be e f f e c t i v e i n preventing these diseases? (Please ind i c a t e which of those diseases which you have chosen have f e a s i b l e preventive programs, by c i r c l i n g the appropriate number). Disease 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 65. Could you describe these programs b r i e f l y ? Thank you for p a r t i c i p a t i n g i n t h i s questionnaire and I hope you w i l l p a r t i c i p a t e i n the time budget study. Name: (Optional) 81 DAY TIME 8:30-9:00 9:00-9:30 9:30-10:00 10:00-10:30 10:30-11:00 11:00-11:30 11:30-12:00 12:00-1:00 1:00-1:30 1:30-2:00 2:00-2:30 2:30-3:00 3:00-3:30 3:30-4:00 4:00-4:30 4:30-5:00 5:00-5:30 TIME STUDY ACTIVITY 

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